Clinical Focus

  • Cancer > Neuro Oncology
  • Neurology
  • Glioma
  • Brain Metastasis
  • Carcinomatosis, Leptomeningeal
  • chemotherapy induced neuropathy
  • Paraneoplastic Syndromes

Academic Appointments

Honors & Awards

  • Who's Who in America, Marquis (2015)
  • Selected Participant, NINDs Clinical Trials Training Course (2011)

Boards, Advisory Committees, Professional Organizations

  • Member, American Society of Clinical Oncology (2010 - Present)
  • Member, Society of Neuro-Oncology (2010 - Present)
  • Member, American Academy of Neurology (2005 - Present)

Professional Education

  • Residency: University of Iowa Hospitals and Clinics (2005) IA
  • Medical Education: Perelman School of Medicine University of Pennsylvania (2004) PA
  • Board Certification: United Council for Neurologic Subspecialties, Neuro-Oncology (2015)
  • Residency: University of California School of Medicine (2009) CA
  • Internship: University of California School of Medicine (2007) CA
  • Fellowship: Stanford University (2011) CA
  • Board Certification: American Board of Psychiatry and Neurology, Neurology (2010)

Current Research and Scholarly Interests

I'm a board certified neuro-oncologist who treats both primary brain tumors as well as metastatic disease to the brain and nervous system. My research concentrates on clinical trials for patients with late-stage central nervous system cancer. I have a special interest in leptomeningeal disease, a devastating complication of lung and breast cancers. I collaborate with Stanford scientists to detect this disease earlier, and with our breast and lung oncologists to improve outcomes for patients.

Clinical Trials

  • A Study of BPM31510 With Vitamin K1 in Subjects With Newly Diagnosed Glioblastoma (GB) Recruiting

    This is a single-arm, non-randomized, open-label Phase 2 therapeutic study that will assess the effects of adding BPM31510 onto a conventional treatment framework of RT and concurrent TMZ chemotherapy for subjects with newly diagnosed glioblastoma.

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  • Molecular Analysis of Thoracic Malignancies Recruiting

    A research study to learn about the biologic features of cancer development, growth, and spread. We are studying components of blood, tumor tissue, normal tissue, and other fluids, such as urine, cerebrospinal fluid, abdominal or chest fluid in patients with cancer. Our analyses of blood, tissue, and/or fluids may lead to improved diagnosis and treatment of cancer by the identification of markers that predict clinical outcome, markers that predict response to specific therapies, and the identification of targets for new therapies.

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  • Study Assessing QBS72S For Treating Brain Metastases Recruiting

    This study is to evaluate the efficacy and safety of QBS72S in participants with advanced, relapsed, metastatic breast cancer with CNS involvement.

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  • Study to Evaluate Safety, Tolerability, and Optimal Dose of Candidate GBM Vaccine VBI-1901 in Recurrent GBM Subjects Recruiting

    The purpose of this study is to assess the safety and tolerability of VBI-1901 in subjects with recurrent malignant gliomas (glioblastoma, or GBM).

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  • [18F]DASA-23 and PET Scan in Evaluating Pyruvate Kinase M2 Expression in Patients With Intracranial Tumors or Recurrent Glioblastoma and Healthy Volunteers Not Recruiting

    This phase I trial studies how well [18F]DASA-23 and positron emission tomography (PET) scan work in evaluating pyruvate kinase M2 (PKM2) expression in patients with intracranial tumors or recurrent glioblastoma and healthy volunteers. PKM2 regulates brain tumor metabolism, a key factor in glioblastoma growth. [18F]DASA-23 is a radioactive substance with the ability to monitor PKM2 activity. A PET scan is a procedure in which a small amount of a radioactive substance, such as [18F]DASA-23, is injected into a vein, and a scanner is used to make detailed, computerized pictures of areas inside the body where the substance is used. Tumor cells usually pick up more of these radioactive substances, allowing them to be found. Giving [18F]DASA-23 with a PET scan may help doctors evaluate PKM2 expression in healthy volunteers and in participants with intracranial tumors or recurrent glioblastoma.

    Stanford is currently not accepting patients for this trial. For more information, please contact Mark M. Santos, 650-498-5189.

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  • A Phase 1b/2, Multicenter, Open-label Study of ACP-196 in Subjects With Recurrent Glioblastoma Multiforme (GBM) Not Recruiting

    A Phase 1b/2, Multicenter, Open-Label Study of ACP-196 in Subjects with Recurrent Glioblastoma Multiforme (GBM)

    Stanford is currently not accepting patients for this trial. For more information, please contact Cathy Recht, 650-723-6095.

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  • A Phase 3, Pivotal Trial of VB-111 Plus Bevacizumab vs. Bevacizumab in Patients With Recurrent Glioblastoma (GLOBE) Not Recruiting

    The purpose of this pivotal, phase 3, randomized, multicenter study is to compare VB-111 plus bevacizumab to bevacizumab in adult patients with recurrent Glioblastoma.

    Stanford is currently not accepting patients for this trial. For more information, please contact Cancer Clinical Trials Office (CCTO), 650-498-7061.

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  • A Study to Evaluate the Safety and Antitumor Activity in Subjects With Advanced Solid Tumors Not Recruiting

    To determine the maximum tolerated dose or optimal biological dose, and the safety profile of MEDI3617 when given as a single-agent or in combination with other chemotherapeutic agents in subjects with advanced solid malignancies resistant to standard therapy.

    Stanford is currently not accepting patients for this trial. For more information, please contact Cathy Kahn Recht, 650725863.

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  • A Therapy Treatment Response Trial in Patients With Leptomeningeal Metastases ((LM) Using CNSide Not Recruiting

    The FORESEE Study is a multi-center, prospective clinical trial enrolling patients with Breast or Non-Small Cell Lung Cancer (NSCLC) who have suspicious or confirmed Leptomeningeal Metastases (LM). Standard of Care methods to diagnose, or assess the treatment response of LM (Clinical Evaluation, MRI and Cytology) have limited sensitivity and specificity. This creates challenges for physicians to manage LM or determine the best course of treatment. CNSide, is a Laboratory Developed Test (LDT ) that is used commercially at the Physician's discretion in Biocept's CLIA certified, CAP accredited laboratory. CNSide can detect and quantify tumor cells in the CSF from patients with Breast Cancer or NSCLC having a suspicious or confirmed LM. The goal of the FORESEE Study is to evaluate the performance of CNSide in monitoring the LM's response to treatment and to assess the impact of CNSide on treatment decisions made by Physicians.

    Stanford is currently not accepting patients for this trial. For more information, please contact Cancer Clinical Trials Office (CCTO), 650-498-7061.

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  • BPM31510 in Treating Patients With Recurrent High-Grade Glioma Previously Treated With Bevacizumab Not Recruiting

    This phase I trial studies the side effects and best dose of ubidecarenone injectable nanosuspension (BPM31510) in treating patients with high-grade glioma (anaplastic astrocytoma or glioblastoma) that has come back and have been previously treated with bevacizumab. BPM31510 may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth.

    Stanford is currently not accepting patients for this trial. For more information, please contact Sophie Bertrand, 650-723-4467.

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  • Brentuximab Vedotin (SGN-35) in Patients With Mycosis Fungoides With Variable CD30 Expression Level Not Recruiting

    The purpose of this study is to learn the effects of brentuximab vedotin (SGN-35), an investigational medication, on patients with cutaneous T cell lymphoma (CTCL), specifically mycosis fungoides (MF) and Sezary syndrome (SS). Despite a wide range of therapeutic options, the treatments are associated with short response duration, thus this condition is largely incurable. This investigational drug may offer less toxicity than standard treatments and have better tumor specific targeting.

    Stanford is currently not accepting patients for this trial. For more information, please contact Kokil Bakshi, 650-421-6370.

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  • Exablate Blood-Brain Barrier Disruption for the Treatment of rGBM in Subjects Undergoing Carboplatin Monotherapy Not Recruiting

    The purpose of this study is to evaluate the safety and feasibility of the Exablate Model 4000 Type 2 system when used as a tool to open the blood-brain-barrier (BBB) in subjects with recurrent glioblastoma (rGBM) undergoing carboplatin monotherapy.

    Stanford is currently not accepting patients for this trial. For more information, please contact Hari Priya Yerraballa, MBBS, 650-724-9363.

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  • Feasibility Study of New Method of Diagnostic and Prediction of Painful CIPN Not Recruiting

    This clinical trial studies how well Diode laser fiber type Selective Stimulator (DLss) works in predicting pain development in patients with ovarian cancer who are receiving chemotherapy. Stimulating of the pain nerve fibers in the skin with laser light stimulation may help to predict whether a patient will develop painful peripheral neuropathy, correlate with the severity of neuropathy during and after chemotherapy treatment, and may help to explain the mechanisms of chemotherapy-induced neuropathic pain (CIPN).

    Stanford is currently not accepting patients for this trial. For more information, please contact Mark Santos, 650-498-5189.

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  • INO-5401 and INO-9012 Delivered by Electroporation (EP) in Combination With Cemiplimab (REGN2810) in Newly-Diagnosed Glioblastoma (GBM) Not Recruiting

    Phase 1/2 trial to evaluate safety, immunogenicity and preliminary efficacy of INO-5401 and INO-9012 in combination with cemiplimab (REGN2810), with radiation and chemotherapy, in subjects with newly-diagnosed glioblastoma (GBM).

    Stanford is currently not accepting patients for this trial. For more information, please contact Cancer Clinical Trials Office (CCTO), 650-498-7061.

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  • Memantine Hydrochloride and Whole-Brain Radiotherapy With or Without Hippocampal Avoidance in Reducing Neurocognitive Decline in Patients With Brain Metastases Not Recruiting

    This randomized phase III trial compares memantine hydrochloride and whole-brain radiotherapy with or without hippocampal avoidance in reducing neurocognitive decline in patients with cancer that has spread from the primary site (place where it started) to the brain. Whole brain radiotherapy (WBRT) is the most common treatment for brain metastasis. Unfortunately, the majority of patients with brain metastases experience cognitive (such as learning and memory) deterioration after WBRT. Memantine hydrochloride may enhance cognitive function by binding to and inhibiting channels of receptors located in the central nervous system. Radiation therapy uses high energy x-rays to kill tumor cells and shrink tumors. Using radiation techniques, such as intensity modulated radiotherapy to avoid the hippocampal region during WBRT, may reduce the radiation dose to the hippocampus and help limit the radiation-induced cognitive decline. It is not yet known whether giving memantine hydrochloride and WBRT with or without hippocampal avoidance works better in reducing neurocognitive decline in patients with brain metastases.

    Stanford is currently not accepting patients for this trial. For more information, please contact Polly Young, 650-497-7499.

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  • Phase 2 Etirinotecan Pegol in Refractory Brain Metastases & Advanced Lung Cancer / Metastatic Breast Cancer Not Recruiting

    This phase 2 trial evaluates how well pegylated irinotecan (NKTR-102) works in treating patients with non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC), or breast cancer (mBC) that has spread to the brain and does not respond to treatment. Pegylated irinotecan may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth.

    Stanford is currently not accepting patients for this trial. For more information, please contact Sophie Bertrand, 650-723-4467.

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  • Pivotal, Randomized, Open-label Study of Optune® (Tumor Treating Fields) Concomitant With RT & TMZ for the Treatment of Newly Diagnosed GBM Not Recruiting

    To test the effectiveness and safety of Optune® given concomitantly with radiation therapy (RT) and temozolomide (TMZ) in newly diagnosed GBM patients, compared to radiation therapy and temozolomide alone. In both arms, Optune® and maintenance temozolomide are continued following radiation therapy.

    Stanford is currently not accepting patients for this trial. For more information, please contact Cancer Clinical Trials Office (CCTO), 650-498-7061.

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  • Safety and Tolerability of ABM-1310 in Patients With Advanced Solid Tumors Not Recruiting

    This is a Phase I, First-In-Human, open label, dose escalation and dose expansion study to evaluate the safety, tolerability, pharmacokinetics, and preliminary anti-cancer activity of ABM-1310 in adult patients with locally advanced or metastatic solid tumors who have no effective standard treatment options available, as monotherapy in patients with documented BRAF V600 mutation, or in combination with cobimetinib (Cotellic®) in adult patients who have documented BRAF mutation and progressive disease or intolerance to at least one prior line of systemic therapy.

    Stanford is currently not accepting patients for this trial.

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  • Study of PBI-200 in Subjects With NTRK-Fusion-Positive Solid Tumors Not Recruiting

    This is a first-in-human, open-label, multicenter, dose-escalation, safety, PK, and biomarker study of PBI-200 in subjects with NTRK-fusion-positive advanced or metastatic solid tumors.

    Stanford is currently not accepting patients for this trial. For more information, please contact Cancer Clinical Trials Office (CCTO), 650-498-7061.

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  • Study of REGN2810 (Anti-PD-1) in Patients With Advanced Malignancies Not Recruiting

    This is a phase 1, open-label, multicenter, ascending-dose escalation study of cemiplimab, alone and in combination with other anti-cancer therapies in patients with advanced malignancies.

    Stanford is currently not accepting patients for this trial. For more information, please contact Cancer Clinical Trials Office (CCTO), 650-498-7061.

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  • The Toca 5 Trial: Toca 511 & Toca FC Versus Standard of Care in Patients With Recurrent High Grade Glioma Not Recruiting

    This is a multicenter, randomized, open-label phase 2/3 study of Toca 511 and Toca FC versus standard of care that comprises Investigator's choice of single agent chemotherapy (lomustine or temozolomide) or bevacizumab administered to subjects undergoing resection for first or second recurrence (including this recurrence) of GBM or AA. Subjects meeting all of the inclusion and none of the exclusion criteria will be randomized prior to surgery in a 1:1 ratio to receive either Toca 511 and Toca FC (Experimental arm, Arm T) or control treatment with one option of standard of care (Arm SOC). Stratification will be done by IDH1 mutation status. A second stratification factor is based on the patient's Karnofsky Performance Score (KPS) (70-80 vs 90-100). Further, to account for potential differences in treatment choices for the control arm in regions, the trial will be stratified by geographical region during the randomization process. Funding Source - FDA OOPD

    Stanford is currently not accepting patients for this trial. For more information, please contact Sophie Bertrand, 650-723-4467.

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  • TTAC-0001 Phase II Trial With Recurrent Glioblastoma Progressed on Bevacizumab Not Recruiting

    This is a phase II, open-Label clinical trial to evaluate the safety and efficacy of TTAC-0001 in patients with recurrent glioblastoma who was progressed on bevacizumab including therapy.

    Stanford is currently not accepting patients for this trial. For more information, please contact Hary Priya Yerraballa, 650-724-9363.

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All Publications

  • Executive Summary of the American Radium Society Appropriate Use Criteria for Brain Metastases in EGFR-mutated and ALK-fusion Non-Small Cell Lung Cancer. Neuro-oncology Nagpal, S., Milano, M. T., Chiang, V. L., Soltys, S. G., Brackett, A., Halasz, L. M., Garg, A. K., Sahgal, A., Ahluwalia, M. S., Tom, M. C., Palmer, J. D., Knisley, J. P., Chao, S. T., Gephart, M. H., Wang, T. J., Lo, S. S., Chang, E. L. 2024


    The American Radium Society (ARS) Central Nervous System (CNS) committee reviewed literature on epidermal growth factor receptor mutated (EGFRm) and ALK-fusion (ALK+) tyrosine kinase inhibitors (TKIs) for the treatment of brain metastases (BrMs) from non-small cell lung cancers (NSCLC) to generate appropriate use guidelines addressing use of TKIs in conjunction with or in lieu of radiotherapy (RT).The panel developed three key questions to guide systematic review: can radiotherapy be deferred in patients receiving EGFR or ALK TKIs at 1) diagnosis or 2) recurrence? Should TKI be administered concurrently with RT (3)? Two literature searches were performed (May 2019 and December 2023). The panel developed 8 model cases and voted on treatment options using a 9-point scale, with 1-3, 4-6 and 7-9 corresponding to usually not appropriate, may be appropriate, and usually appropriate (respectively), per the UCLA/RAND Appropriateness Method.Consensus was achieved in only 4 treatment scenarios, all consistent with existing ARS-AUC guidelines for multiple BrM. The panel did not reach consensus that RT can be appropriately deferred in patients with BrM receiving CNS penetrant ALK or EGFR TKIs, though median scores indicated deferral may be appropriate under most circumstances. Whole brain RT with concurrent TKI generated broad disagreement except in cases with 2-4 BrM, where it was considered usually not appropriate.We identified no definitive studies dictating optimal sequencing of TKIs and RT for EGFRm and ALK+ BrM. Until such studies are completed, the committee hopes these cases guide decision-making in this complex clinical space.

    View details for DOI 10.1093/neuonc/noae041

    View details for PubMedID 38459978

  • Global metabolomics revealed deviations from the metabolic aging clock in colorectal cancer patients. Theranostics Zhang, L., Mo, S., Zhu, X., Chou, C. J., Jin, B., Han, Z., Schilling, J., Liao, W., Thyparambil, S., Luo, R. Y., Whitin, J. C., Tian, L., Nagpal, S., Ceresnak, S. R., Cohen, H. J., McElhinney, D. B., Sylvester, K. G., Gong, Y., Fu, C., Ling, X. B., Peng, J. 2024; 14 (4): 1602-1614


    Background: Markers of aging hold promise in the context of colorectal cancer (CRC) care. Utilizing high-resolution metabolomic profiling, we can unveil distinctive age-related patterns that have the potential to predict early CRC development. Our study aims to unearth a panel of aging markers and delve into the metabolomic alterations associated with aging and CRC. Methods: We assembled a serum cohort comprising 5,649 individuals, consisting of 3,002 healthy volunteers, 715 patients diagnosed with colorectal advanced precancerous lesions (APL), and 1,932 CRC patients, to perform a comprehensive metabolomic analysis. Results: We successfully identified unique age-associated patterns across 42 metabolic pathways. Moreover, we established a metabolic aging clock, comprising 9 key metabolites, using an elastic net regularized regression model that accurately estimates chronological age. Notably, we observed significant chronological disparities among the healthy population, APL patients, and CRC patients. By combining the analysis of circulative carcinoembryonic antigen levels with the categorization of individuals into the "hypo" metabolic aging subgroup, our blood test demonstrates the ability to detect APL and CRC with positive predictive values of 68.4% (64.3%, 72.2%) and 21.4% (17.8%, 25.9%), respectively. Conclusions: This innovative approach utilizing our metabolic aging clock holds significant promise for accurately assessing biological age and enhancing our capacity to detect APL and CRC.

    View details for DOI 10.7150/thno.87303

    View details for PubMedID 38389840

    View details for PubMedCentralID PMC10879879

  • Ready to INDIGO: Vorasidenib Ushers in the Era of Isocitrate Dehydrogenase Inhibition in Low-Grade Glioma. International journal of radiation oncology, biology, physics Lanman, T. A., Cao, T. Q., Miller, J. J., Nagpal, S. 2024; 118 (2): 334-336

    View details for DOI 10.1016/j.ijrobp.2023.10.045

    View details for PubMedID 38220256

  • A rare non-gadolinium enhancing sarcoma brain metastasis with microenvironment dominated by tumor-associated macrophages. Acta neuropathologica communications Rogawski, D., Wheeler, J., Nie, E., Zhu, W., Villanueva, E., Coffey, G., Ma, Q., Ganjoo, K., Fischbein, N., Iv, M., Vogel, H., Nagpal, S. 2024; 12 (1): 15


    Brain metastases occur in 1% of sarcoma cases and are associated with a median overall survival of 6 months. We report a rare case of a brain metastasis with unique radiologic and histopathologic features in a patient with low grade fibromyxoid sarcoma (LGFMS) previously treated with immune checkpoint inhibitor (ICI) therapy. The lone metastasis progressed in the midbrain tegmentum over 15 months as a non-enhancing, T2-hyperintense lesion with peripheral diffusion restriction, mimicking a demyelinating lesion. Histopathology of the lesion at autopsy revealed a rich infiltrate of tumor-associated macrophages (TAMs) with highest density at the leading edge of the metastasis, whereas there was a paucity of lymphocytes, suggestive of an immunologically cold environment. Given the important immunosuppressive and tumor-promoting functions of TAMs in gliomas and carcinoma/melanoma brain metastases, this unusual case provides an interesting example of a dense TAM infiltrate in a much rarer sarcoma brain metastasis.

    View details for DOI 10.1186/s40478-023-01713-8

    View details for PubMedID 38254244

    View details for PubMedCentralID 5021195

  • Impact of language barriers and use of interpreters on hope among patients with Central Nervous System Malignancies and Bone Metastases. International journal of radiation oncology, biology, physics Hui, C., Hall, J., Fang, Z., Lefebvre, S., Hayden-Gephart, M., Li, G., Meola, A., Nagpal, S., Soltys, S., Pollom, E. 2023


    PURPOSE: Hope is important in serious illnesses, as it has been linked to patient quality of life. We aimed to determine factors associated with lower hope scores among patients with central nervous system (CNS) disease or bone metastases.METHODS: The Adult Dispositional Hope Scale (AHS) is a 12-item questionnaire that measures hope through two qualities: agency (goal-directed energy) and pathways (plan to meet goals). Total scores range from 8 to 64, with higher scores reflecting higher agency and pathways thinking. We prospectively collected scores from patients seen in two radiation oncology clinics at our institution from 10/2022 to 4/2023. The method of least squares to fit general linear models and Pearson's correlation coefficients (PCC) was used to determine relationships between AHS score and socioeconomic and disease factors.RESULTS: Of the 197 patients who responded, median age was 60.5 years (range 16.9-92.5 years), most patients were male (60.9%), white (59.4%), and had malignant disease (59.4%). Median overall AHS score was 54 (range 8-64), and median pathway and agency thinking scores were 27 (range 4-32) and 27 (range 4-32), respectively. Patients who needed an interpreter compared to those who did not had significantly lower overall AHS scores (mean score 45.4 versus 51.2, respectively; p=0.0493) and pathway thinking scores (mean score 21.5 versus 25.7, respectively; p=0.0085), and patients with poorer performance status had significantly worse overall AHS scores (PCC=-0.2703, p=0.0003).CONCLUSION: Patients with CNS disease or bone metastases requiring the use of an interpreter had lower AHS scores, highlighting the possible association of language barriers to hope. Addressing patient language barriers and further studies on the possible association of language barriers to hope may improve hope, quality of life and outcomes among these patients.

    View details for DOI 10.1016/j.ijrobp.2023.11.056

    View details for PubMedID 38056777

  • Tumor treating fields increases blood-brain barrier permeability and relative cerebral blood volume in patients with glioblastoma. The neuroradiology journal Iv, M., Naya, L., Sanan, S., Van Buskirk, S. L., Nagpal, S., Thomas, R. P., Recht, L. D., Patel, C. B. 2023: 19714009231207083


    200 kHz tumor treating fields (TTFields) is clinically approved for newly-diagnosed glioblastoma (nGBM). Because its effects on conventional surveillance MRI brain scans are equivocal, we investigated its effects on perfusion MRI (pMRI) brain scans.Each patient underwent institutional standard pMRI: dynamic contrast-enhanced (DCE) and dynamic susceptibility contrast (DSC) pMRI at three time points: baseline, 2-, and 6-months on-adjuvant therapy. At each timepoint, the difference between T1 pre- versus post-contrast tumor volume (ΔT1) and these pMRI metrics were evaluated: normalized and standardized relative cerebral blood volume (nRCBV, sRCBV); fractional plasma volume (Vp), volume of extravascular extracellular space (EES) per volume of tissue (Ve), blood-brain barrier (BBB) permeability (Ktrans), and time constant for gadolinium reflux from EES back into the vascular system (Kep). Between-group comparisons were performed using rank-sum analysis, and bootstrapping evaluated likely reproducibility of the results.Among 13 pMRI datasets (11 nGBM, 2 recurrent GBM), therapies included temozolomide-only (n = 9) and temozolomide + TTFields (n = 4). No significant differences were found in patient or tumor characteristics. Compared to temozolomide-only, temozolomide + TTFields did not significantly affect the percent-change in pMRI metrics from baseline to 2 months. But during the 2- to 6-month period, temozolomide + TTFields significantly increased the percent-change in nRCBV (+26.9% [interquartile range 55.1%] vs -39.1% [37.0%], p = 0.049), sRCBV (+9.5% [39.7%] vs -30.5% [39.4%], p = 0.049), Ktrans (+54.6% [1768.4%] vs -26.9% [61.2%], p = 0.024), Ve (+111.0% [518.1%] vs -13.0% [22.5%], p = 0.048), and Vp (+98.8% [2172.4%] vs -24.6% [53.3%], p = 0.024) compared to temozolomide-only.Using pMRI, we provide initial in-human validation of pre-clinical studies regarding the effects of TTFields on tumor blood volume and BBB permeability in GBM.

    View details for DOI 10.1177/19714009231207083

    View details for PubMedID 37931176

  • INTERNAL CAROTID INJECTION MODEL OF BRAIN METASTASIS DESCRIBES LEPTOMENINGEAL DISEASE Chernikova, S., Tsau, S., Wang, Y., Hartmann, G., Polyak, D., Bhambhvani, H., Kolluru, S., Thy Trinh, Casey, K., Johnson, E., Connolly, I., Recht, L., Ahn, G., Nagpal, S., Quake, S., Brown, J., Gephart, M. OXFORD UNIV PRESS INC. 2023
  • A RANDOMIZED WINDOW OF OPPORTUNITY TRIAL WITH DOSE ESCALATION TO EVALUATE FLUOXETINE AND TEMOZOLOMIDE IN GLIOMA Singh, K., Railton, C., Hotchkiss, K., Herndon, J., Peters, K., Friedman, H., Desjardins, A., Ashley, D., Johnson, M. O., Patel, A., Friedman, A., Lim, M., Fecci, P., Piccioni, D., McGranahan, T., Nagpal, S., Sulman, E., Mischel, P., Khasraw, M. OXFORD UNIV PRESS INC. 2023
  • TRIAL IN PROGRESS: A PHASE 2 STUDY OF BPM 31510 (AN OXIDIZED COQ10-LIPID CONJUGATE NANODISPERSION) WITH VITAMIN K AND STANDARD CHEMORADIATION IN NEWLY DIAGNOSED GLIOBLASTOMA Stocksdale, B., Bertrand, S., Villanueva, E., Naya, L., Molaie, D., Lyng, A., Berman, B., Vishnudas, V., Kiebish, M., Gesta, S., Narain, N., Recht, L., Nagpal, S. OXFORD UNIV PRESS INC. 2023
  • High-throughput quantitation of amino acids and acylcarnitine in cerebrospinal fluid: identification of PCNSL biomarkers and potential metabolic messengers FRONTIERS IN MOLECULAR BIOSCIENCES Ma, J., Chen, K., Ding, Y., Li, X., Tang, Q., Jin, B., Luo, R. Y., Thyparambil, S., Han, Z., Chou, C., Zhou, A., Schilling, J., Lin, Z., Ma, Y., Li, Q., Zhang, M., Sylvester, K. G., Nagpal, S., McElhinney, D. B., Ling, X. B., Chen, B. 2023; 10
  • High-throughput quantitation of amino acids and acylcarnitine in cerebrospinal fluid: identification of PCNSL biomarkers and potential metabolic messengers. Frontiers in molecular biosciences Ma, J., Chen, K., Ding, Y., Li, X., Tang, Q., Jin, B., Luo, R. Y., Thyparambil, S., Han, Z., Chou, C. J., Zhou, A., Schilling, J., Lin, Z., Ma, Y., Li, Q., Zhang, M., Sylvester, K. G., Nagpal, S., McElhinney, D. B., Ling, X. B., Chen, B. 2023; 10: 1257079


    Background: Due to the poor prognosis and rising occurrence, there is a crucial need to improve the diagnosis of Primary Central Nervous System Lymphoma (PCNSL), which is a rare type of non-Hodgkin's lymphoma. This study utilized targeted metabolomics of cerebrospinal fluid (CSF) to identify biomarker panels for the improved diagnosis or differential diagnosis of primary central nervous system lymphoma (PCNSL). Methods: In this study, a cohort of 68 individuals, including patients with primary central nervous system lymphoma (PCNSL), non-malignant disease controls, and patients with other brain tumors, was recruited. Their cerebrospinal fluid samples were analyzed using the Ultra-high performance liquid chromatography - tandem mass spectrometer (UHPLC-MS/MS) technique for targeted metabolomics analysis. Multivariate statistical analysis and logistic regression modeling were employed to identify biomarkers for both diagnosis (Dx) and differential diagnosis (Diff) purposes. The Dx and Diff models were further validated using a separate cohort of 34 subjects through logistic regression modeling. Results: A targeted analysis of 45 metabolites was conducted using UHPLC-MS/MS on cerebrospinal fluid (CSF) samples from a cohort of 68 individuals, including PCNSL patients, non-malignant disease controls, and patients with other brain tumors. Five metabolic features were identified as biomarkers for PCNSL diagnosis, while nine metabolic features were found to be biomarkers for differential diagnosis. Logistic regression modeling was employed to validate the Dx and Diff models using an independent cohort of 34 subjects. The logistic model demonstrated excellent performance, with an AUC of 0.83 for PCNSL vs. non-malignant disease controls and 0.86 for PCNSL vs. other brain tumor patients. Conclusion: Our study has successfully developed two logistic regression models utilizing metabolic markers in cerebrospinal fluid (CSF) for the diagnosis and differential diagnosis of PCNSL. These models provide valuable insights and hold promise for the future development of a non-invasive and reliable diagnostic tool for PCNSL.

    View details for DOI 10.3389/fmolb.2023.1257079

    View details for PubMedID 38028545

    View details for PubMedCentralID PMC10644155

  • A Single-Institution Retrospective Series of SARS-CoV-2 Infection in Adult Glioma Patients. Case reports in oncology Lanman, T., Ruiz, A. N., Nagpal, S. 2023; 16 (1): 980-987


    A subset of cancer patients is particularly vulnerable to SARS-CoV-2 infection; however, real-world outcomes-based data on primary central nervous system tumor patients is sparse. This retrospective series describes a cohort of adult glioma patients seen at Stanford Cancer Center between January 1, 2020, and June 30, 2022 who contracted SARS-CoV-2, which, to our knowledge, currently represents the largest single-institution comprehensive analysis of this patient population. We performed a retrospective search of patients seen in the Stanford Neuro-Oncology clinic, identifying 29 cases of COVID-19 amongst glioma patients and extracted clinical data via individual chart review. At the time of COVID-19 diagnosis, 15 patients had been vaccinated against SARS-CoV-2, 8 patients were taking dexamethasone, and 8 were undergoing cancer-specific treatment. Obesity, prior tobacco use, and diabetes were the most common comorbidities. Cough, sore throat, and congestion were the most common symptoms. Five patients were admitted to the hospital and two received COVID-19-specific treatment. None died from COVID-related causes or complications. Our data suggest that glioma patients seen at Stanford Cancer Center do not experience an exceptionally high COVID-19 infectivity, hospitalization, or mortality rate, especially when compared to other vulnerable populations such as lung cancer patients. High vaccination rates, adherence to COVID-19 guidelines, and low prevalence of comorbidities may have contributed to these results.

    View details for DOI 10.1159/000531836

    View details for PubMedID 37900820

    View details for PubMedCentralID PMC10601729

  • A phase 1, multicenter, open-label study of a new BRAF inhibitor ABM-1310 in adult patients (pts) with BRAFv600-mutated solid tumors. Piha-Paul, S. A., Nagpal, S., Weise, A. M., Braiteh, F. S., Chen, C., Huang, C., Liu, W., Hu, Y., Yang, Z., Tsai, K. K. LIPPINCOTT WILLIAMS & WILKINS. 2023
  • Phase 3 TRIDENT study (EF-32): Tumor treating fields (TTFields; 200 kHz) concomitant with chemoradiation, and maintenance TTFields therapy/temozolomide in newly diagnosed glioblastoma Shi, W., Roberge, D., Kleinberg, L., Jeyapalan, S. A., Goldlust, S., Nagpal, S., Lustgarten, L., Combs, S. E., Nishikawa, R., Reardon, D. A., Grossman, R., Glas, M. LIPPINCOTT WILLIAMS & WILKINS. 2023
  • Diagnostic and Therapeutic Updates in Leptomeningeal Disease. Current oncology reports Roy-O'Reilly, M. A., Lanman, T., Ruiz, A., Rogawski, D., Stocksdale, B., Nagpal, S. 2023


    PURPOSE OF REVIEW: Leptomeningeal disease (LMD) is a devastating complication of advanced metastatic cancer associated with a poor prognosis and limited treatment options. This study reviews the current understanding of the clinical presentation, pathogenesis, diagnosis, and treatment of LMD. We highlight opportunities for advances in this disease.RECENT FINDINGS: In recent years, the use of soluble CSF biomarkers has expanded, suggesting improved sensitivity over traditional cytology, identification of targetable mutations, and potential utility for monitoring disease burden. Recent studies of targeted small molecules and intrathecal based therapies have demonstrated an increase in overall and progression-free survival. In addition, there are several ongoing trials evaluating immunotherapy in LMD. Though overall prognosis of LMD remains poor, studies suggest a potential role for soluble CSF biomarkers in diagnosis and management and demonstrate promising findings in patient outcomes with targeted therapies for specific solid tumors. Despite these advances, there continues to be a gap of knowledge in this disease, emphasizing the importance of inclusion of LMD patients in clinical trials.

    View details for DOI 10.1007/s11912-023-01432-2

    View details for PubMedID 37256537

  • Parental Leave Experience for Academic Neurology Faculty at 19 Academic Centers He, A., Grewal, P., Rodrigues, K., Shah, S., Alexander, H., Yang, A., Ayub, N., Nobleza, C., Kung, D., Frost, N., Nagpal, S., Durica, S., Silver, J., Patel, S., Allendorfer, J., Alick-Lindstrom, S. LIPPINCOTT WILLIAMS & WILKINS. 2023
  • Impact of Gender and Race on Academic Achievements for Neurology Faculty Patel, S., Grewal, P., Nobleza, C., Ayub, N., Kung, D., Shah, S., Abdennadher, M., Alexander, H., Frost, N., Nagpal, S., Durica, S., Yoshii-Contreras, J., Zarroli, K., Sudhakar, P., Zhao, C., De Jesus, S., Bradshaw, D., Brescia, N., Foldvary-Schaefer, N., Tormoehlen, L., Mantri, S., Gutmann, L., Yang, A., He, A., Zheng, C., Howard, V., Silver, J., Westring, A., Alick-Lindstrom, S., Allendorfer, J. LIPPINCOTT WILLIAMS & WILKINS. 2023
  • Real-world risk of brain metastases in stage III non-small cell lung cancer in the era of PET and MRI staging. Frontiers in oncology Alhusaini, S., Lanman, T. A., Ko, R. B., Therkelsen, K. E., Eyben, R. V., Diehn, M., Soltys, S. G., Pollom, E. L., Chin, A., Vitzthum, L., Wakelee, H. A., Padda, S. K., Ramchandran, K., Loo, B. W., Neal, J. W., Nagpal, S. 2023; 13: 1139940


    The 2-year incidence of brain metastases (BrMs) in stage III non-small lung cell cancer (NSCLC) has been estimated to be around 30%. However, recent clinical trials have demonstrated considerably lower BrMs rates in this patient population. In this study, we aimed to review the real-world incidence, surveillance, and treatment patterns of BrMs in stage III NSCLC.Using a retrospective single-center study design, we identified patients with stage III NSCLC who received radiation with curative intent over a 10-year period. Outcome variables included BrMs incidence, overall survival (OS), and survival from date of BrMs. Additionally, we assessed patterns of BrMs surveillance in stage III NSCLC and treatment.We identified a total of 279 stage III NSCLC patients, of which 160 with adequate records were included in the final analyses [adenocarcinoma (n = 96), squamous cell carcinoma (n = 53), other histology subtype (n = 11)]. The median OS for the entire cohort was 41 months (95% CI, 28-53), while the median time from BrMs to death was 19 months (95% CI, 9-21). Twenty-three patients (14.4%) received planned surveillance brain MRIs at 6, 12, and 24 months after completion of treatment. The remaining 137 patients (85.6%) received brain MRIs at systemic recurrence (restaging) or when neurologically symptomatic. A total of 37 patients (23%) developed BrMs, with a 2-year cumulative BrMs incidence of 17% (95% CI, 11-23). A higher incidence of BrMs was identified in patients with adenocarcinoma relative to those with squamous cell carcinoma (p < 0.01). Similarly, a higher 2-year BrMs incidence was observed in patients who received planned surveillance brain MRI relative to those who did not, although statistical significance was not reached. Stereotactic radiosurgery (SRS) treated 29 of BrMs patients (78.4%) and was preferred over WBRT, which treated only 3 patients (8.1%).At our center, BrMs incidence in stage III NSCLC patients was lower than historically reported but notably higher than the incidence described in recent clinical trials. Routine BrMs surveillance potentially allows earlier detection of asymptomatic BrMs. However, asymptomatic BrMs were mostly detected on restaging MRI at the time of recurrence.

    View details for DOI 10.3389/fonc.2023.1139940

    View details for PubMedID 37035171

    View details for PubMedCentralID PMC10080021

  • Patterns of Progression in Patients with Newly Diagnosed Glioblastoma Treated with 5 mm Margins on a Phase I/II Trial of 5 Fraction Stereotactic Radiosurgery with Concurrent and Adjuvant Temozolomide. Practical radiation oncology Mendoza, M. G., Azoulay, M., Chang, S. D., Gibbs, I. C., Hancock, S. L., Pollom, E. L., Adler, J. R., Harraher, C., Li, G., Gephart, M. H., Nagpal, S., Thomas, R. P., Recht, L. D., Jacobs, L. R., Modlin, L. A., Wynne, J., Seiger, K., Fujimoto, D., Usoz, M., von Eyben, R., Choi, C. Y., Soltys, S. G. 2023


    BACKGROUND: In patients with newly diagnosed glioblastoma (GBM), tumor margins of at least 20 mm are the standard of care. We sought to determine the pattern of tumor progression in patients treated with 5 fraction stereotactic radiosurgery (SRS) with 5 mm margins.METHODS: Thirty adult patients with newly diagnosed GBM were treated with 5 fraction SRS in escalated doses from 25 Gy to 40 Gy with a 5 mm total treatment margin. Progression was scored as 'in-field' if the recurrent tumor was within or contiguous with the 5 mm margin, 'marginal' if between 5 and 20 mm, and 'distant' if entirely occurring greater than 20 mm. As geometric patterns of progression do not reflect the biologic dose received, we calculated the minimum equieffective dose in 2 Gy per day (EQD2) at the site of tumor recurrence. Progression was 'dosimetrically in-field' if covered by a minimum EQD2 of 48 Gy10.RESULTS: From 2010 to 2016, 27 patients had progressed. Progression was in-field in 17 (63%), marginal in 3 (11%) and distant in 7 (26%) patients. In the 3 patients with marginal progression, the minimum EQD2 to recurrent tumor were 48 Gy10, 56 Gy10 (both considered dosimetrically in-field) and 7 Gy10 (i.e., dosimetrically out-of-field). Median overall survival (OS) was 12.1 months for in-field (95%CI 8.9-17.6), 15.1 months (95%CI 10.1-not achieved) for marginal and 21.4 months (95%CI 11.2-33.5) for distant progression. Patients with radiation necrosis were less likely to have in-field progression (1 of 7; 14%) compared to those without radiation necrosis (16 of 20; 80%; p = 0.003); those with necrosis had a median overall survival of 27.2 months (95%CI 11.2-48.3) compared to 11.7 months (95%CI 8.9-17.6) for patients with no necrosis (p = 0.077).CONCLUSION: In patients with newly diagnosed GBM treated with a 5 mm CTV margin, 3 patients (11%) had marginal progression within 5-20 mm; only 1 patient (4%) may have dosimetrically benefitted from conventional 20 mm margins. Radiation necrosis was associated with in-field tumor control.

    View details for DOI 10.1016/j.prro.2023.01.008

    View details for PubMedID 36736621

  • NCCN Guidelines Insights: Central Nervous System Cancers, Version 2.2022. Journal of the National Comprehensive Cancer Network : JNCCN Horbinski, C., Nabors, L. B., Portnow, J., Baehring, J., Bhatia, A., Bloch, O., Brem, S., Butowski, N., Cannon, D. M., Chao, S., Chheda, M. G., Fabiano, A. J., Forsyth, P., Gigilio, P., Hattangadi-Gluth, J., Holdhoff, M., Junck, L., Kaley, T., Merrell, R., Mrugala, M. M., Nagpal, S., Nedzi, L. A., Nevel, K., Nghiemphu, P. L., Parney, I., Patel, T. R., Peters, K., Puduvalli, V. K., Rockhill, J., Rusthoven, C., Shonka, N., Swinnen, L. J., Weiss, S., Wen, P. Y., Willmarth, N. E., Bergman, M. A., Darlow, S. 2023; 21 (1): 12-20


    The NCCN Guidelines for Central Nervous System (CNS) Cancers focus on management of the following adult CNS cancers: glioma (WHO grade 1, WHO grade 2-3 oligodendroglioma [1p19q codeleted, IDH-mutant], WHO grade 2-4 IDH-mutant astrocytoma, WHO grade 4 glioblastoma), intracranial and spinal ependymomas, medulloblastoma, limited and extensive brain metastases, leptomeningeal metastases, non-AIDS-related primary CNS lymphomas, metastatic spine tumors, meningiomas, and primary spinal cord tumors. The information contained in the algorithms and principles of management sections in the NCCN Guidelines for CNS Cancers are designed to help clinicians navigate through the complex management of patients with CNS tumors. Several important principles guide surgical management and treatment with radiotherapy and systemic therapy for adults with brain tumors. The NCCN CNS Cancers Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights summarize the panel's most recent recommendations regarding molecular profiling of gliomas.

    View details for DOI 10.6004/jnccn.2023.0002

    View details for PubMedID 36634606

  • Local Control of Brain Metastases with Osimertinib Alone in Patients with EGFR-Mutant Non-Small Cell Lung Cancer Hui, C., Qu, V., Wang, J. Y., Von Eyben, R., Chang, Y. C., Chiang, P. L., Liang, C. H., Lin, J. Y., Lu, J. T., Li, G., Hayden, M., Myall, N., Soltys, S. G., Pollom, E. ELSEVIER SCIENCE INC. 2022: E54-E55
  • A MULTI-INSTITUTIONAL RETROSPECTIVE SERIES OF ADULT-ONSET MEDULLOBLASTOMA. Bonm, A., Rutenberg, M., Therkelsen, K., Ruiz, A., McGranahan, T., Cimino, P., Nagpal, S., Taylor, L. OXFORD UNIV PRESS INC. 2022: 85
  • ANIMAL STUDIES WITH A NEW CNS DRUG DELIVERY DEVICE TO EFFECTIVELY TREAT LEPTOMENINGEAL CARCINOMATOSIS PATIENTS Kumthekar, P., Benatti, H., Taghian, T., Gormley, W. B., Nagpal, S., Baker, W. C., Patel, R., Brown, E., Glicksman, M., Gray-Edwards, H. OXFORD UNIV PRESS INC. 2022: 94
  • Local control of brain metastases with osimertinib alone in patients with EGFR-mutant non-small cell lung cancer. Journal of neuro-oncology Hui, C., Qu, V., Wang, J. Y., von Eyben, R., Chang, Y. C., Chiang, P. L., Liang, C. H., Lu, J. T., Li, G., Hayden-Gephart, M., Wakelee, H., Neal, J., Ramchandran, K., Das, M., Nagpal, S., Soltys, S., Myall, N., Pollom, E. 2022


    Although osimertinib has excellent intracranial activity in metastatic non-small cell lung cancer (NSCLC) with exon 19 deletion or L858R EGFR alterations, measures of local control of brain metastases are less well-reported. We describe lesion-level outcomes of brain metastases treated with osimertinib alone.We retrospectively reviewed patients with EGFR-mutant NSCLC with untreated brain metastasis measuring ≥ 5 mm at the time of initiating osimertinib. Cumulative incidence of local recurrence in brain (LRiB) was calculated with death as a competing risk, and univariable and multivariable analyses were conducted to identify factors associated with LRiB.We included 284 brain metastases from 37 patients. Median follow-up was 20.1 months. On initial MRI after starting osimertinib, patient-level response was complete response (CR) in 11 (15%), partial response (PR) in 33 (45%), stable disease (SD) in 18 (25%) and progressive disease (PD) in 11 (15%). The 1-year cumulative incidence of LRiB was 14% (95% CI 9.9-17.9) and was significantly different in patients with a CR (0%), PR (4%), and SD (11%; p = 0.02). Uncontrolled primary tumor (adjusted hazard ratio [aHR] 3.78, 95% CI 1.87-7.66; p < 0.001), increasing number of prior systemic therapies (aHR 2.12, 95% CI 1.49-3.04; p < 0.001), and higher ECOG score (aHR 7.8, 95% CI 1.99-31.81; p = 0.003) were associated with LRiB.Although 1-year cumulative incidence of LRiB is < 4% with a CR or PR, 1-year cumulative incidence of LRiB is over 10% for patients with less than a PR to osimertinib on initial MRI. These patients should be followed closely for need for additional treatment such as stereotactic radiosurgery.

    View details for DOI 10.1007/s11060-022-04145-x

    View details for PubMedID 36227422

  • Predictive Model to Guide Brain Magnetic Resonance Imaging Surveillance in Patients With Metastatic Lung Cancer: Impact on Real-World Outcomes. JCO precision oncology Wu, J., Ding, V., Luo, S., Choi, E., Hellyer, J., Myall, N., Henry, S., Wood, D., Stehr, H., Ji, H., Nagpal, S., Hayden Gephart, M., Wakelee, H., Neal, J., Han, S. S. 2022; 6: e2200220


    Brain metastasis is common in lung cancer, and treatment of brain metastasis can lead to significant morbidity. Although early detection of brain metastasis may improve outcomes, there are no prediction models to identify high-risk patients for brain magnetic resonance imaging (MRI) surveillance. Our goal is to develop a machine learning-based clinicogenomic prediction model to estimate patient-level brain metastasis risk.A penalized regression competing risk model was developed using 330 patients diagnosed with lung cancer between January 2014 and June 2019 and followed through June 2021 at Stanford HealthCare. The main outcome was time from the diagnosis of distant metastatic disease to the development of brain metastasis, death, or censoring.Among the 330 patients, 84 (25%) developed brain metastasis over 627 person-years, with a 1-year cumulative brain metastasis incidence of 10.2% (95% CI, 6.8 to 13.6). Features selected for model inclusion were histology, cancer stage, age at diagnosis, primary site, and RB1 and ALK alterations. The prediction model yielded high discrimination (area under the curve 0.75). When the cohort was stratified by risk using a 1-year risk threshold of > 14.2% (85th percentile), the high-risk group had increased 1-year cumulative incidence of brain metastasis versus the low-risk group (30.8% v 6.1%, P < .01). Of 48 high-risk patients, 24 developed brain metastasis, and of these, 12 patients had brain metastasis detected more than 7 months after last brain MRI. Patients who missed this 7-month window had larger brain metastases (58% v 33% largest diameter > 10 mm; odds ratio, 2.80, CI, 0.51 to 13) versus those who had MRIs more frequently.The proposed model can identify high-risk patients, who may benefit from more intensive brain MRI surveillance to reduce morbidity of subsequent treatment through early detection.

    View details for DOI 10.1200/PO.22.00220

    View details for PubMedID 36201713

  • Preclinical Modeling in Leptomeningeal Disease: Starting at the foundation to tackle a difficult disease. Neuro-oncology Kumthekar, P., Nagpal, S. 2022

    View details for DOI 10.1093/neuonc/noac142

    View details for PubMedID 35751573

  • Intramuscular (IM) INO-5401+INO-9012 with electroporation (EP) in combination with cemiplimab (REGN2810) in newly diagnosed glioblastoma. Reardon, D. A., Brem, S., Desai, A., Bagley, S., Kurz, S., De La Fuente, M., Nagpal, S., Welch, M., Hormigo, A., Forsyth, P. J., Mandel, J., Khagi, S., Aiken, R., Walbert, T., Lieberman, F. S., Portnow, J., Battiste, J., Gillespie, E., Lowy, I., Skolnik, J. LIPPINCOTT WILLIAMS & WILKINS. 2022
  • Radiation Therapy for Brain Metastases: An ASTRO Clinical Practice Guideline. Practical radiation oncology Gondi, V., Bauman, G., Bradfield, L., Burri, S. H., Cabrera, A. R., Cunningham, D. A., Eaton, B. R., Hattangadi-Gluth, J. A., Kim, M. M., Kotecha, R., Kraemer, L., Li, J., Nagpal, S., Rusthoven, C. G., Suh, J. H., Tome, W. A., Wang, T. J., Zimmer, A. S., Ziu, M., Brown, P. D. 2022


    PURPOSE: This guideline provides updated evidence-based recommendations addressing recent developments in the management of patients with brain metastases, including advanced radiation therapy techniques such as stereotactic radiosurgery (SRS) and hippocampal avoidance whole brain radiation therapy and the emergence of systemic therapies with central nervous system activity.METHODS: The American Society for Radiation Oncology convened a task force to address 4 key questions focused on the radiotherapeutic management of intact and resected brain metastases from nonhematologic solid tumors. The guideline is based on a systematic review provided by the Agency for Healthcare Research and Quality. Recommendations were created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength.RESULTS: Strong recommendations are made for SRS for patients with limited brain metastases and Eastern Cooperative Oncology Group performance status 0 to 2. Multidisciplinary discussion with neurosurgery is conditionally recommended to consider surgical resection for all tumors causing mass effect and/or that are greater than 4 cm. For patients with symptomatic brain metastases, upfront local therapy is strongly recommended. For patients with asymptomatic brain metastases eligible for central nervous system-active systemic therapy, multidisciplinary and patient-centered decision-making to determine whether local therapy may be safely deferred is conditionally recommended. For patients with resected brain metastases, SRS is strongly recommended to improve local control. For patients with favorable prognosis and brain metastases receiving whole brain radiation therapy, hippocampal avoidance and memantine are strongly recommended. For patients with poor prognosis, early introduction of palliative care for symptom management and caregiver support are strongly recommended.CONCLUSIONS: The task force has proposed recommendations to inform best clinical practices on the use of radiation therapy for brain metastases with strong emphasis on multidisciplinary care.

    View details for DOI 10.1016/j.prro.2022.02.003

    View details for PubMedID 35534352

  • Executive summary of american radium society's appropriate use criteria for the postoperative management of lower grade gliomas. Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology Tom, M. C., Milano, M. T., Chao, S. T., Soltys, S. G., Knisely, J. P., Sahgal, A., Nagpal, S., Lo, S. S., Jabbari, S., Wang, T. J., Ahluwalia, M. S., Simonson, M., Palmer, J. D., Gephart, M. H., Halasz, L. M., Garg, A. K., Chiang, V. L., Chang, E. L. 2022


    Postoperative management of lower grade gliomas (grade 2 and 3) is heterogeneous. The American Radium Society's brain malignancies panel systematically reviewed and evaluated the literature to develop consensus guidelines addressing timing of postoperative therapy, monotherapy versus combined modality therapy, type of chemotherapy used with radiotherapy, and radiotherapy dose. Thirty-six studies were included. Using consensus methodology (modified Delphi), the panel voted upon representative case variants using a 9-point appropriateness scale to address key questions. Voting results were collated to develop summarized recommendations. Following gross-total surgical resection, close surveillance is appropriate for well-selected grade 2, IDH-mutant oligodendrogliomas or astrocytomas with low-risk features. For grade 2 gliomas with high-risk features or any grade 3 glioma, immediate adjuvant therapy is recommended. When postoperative therapy is administered, radiation and planned chemotherapy is strongly recommended over monotherapy. For grade 2 and 3 IDH-mutant oligodendrogliomas and astrocytomas, either adjunctive PCV (procarbazine, lomustine, vincristine) or temozolomide is appropriate. For grade 3 IDH-mutant astrocytomas, radiotherapy followed by temozolomide is strongly recommended. The recommended radiotherapy dose for grade 2 gliomas is 45-54 Gy/1.8-2.0 Gy, and for grade 3 gliomas is 59.4-60 Gy/1.8-2.0 Gy. While multiple appropriate treatment options exist, these consensus recommendations provide an evidence-based framework to approach postoperative management of lower grade gliomas.

    View details for DOI 10.1016/j.radonc.2022.03.018

    View details for PubMedID 35367527

  • In Response to: "Comparing Addition of Radiotherapy in EGFR- and ALK-Positive NSCLC With Brain Metastases: Are We Evaluating the Optimal Endpoint?" Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer Thomas, N. J., Myall, N. J., Sun, F., Patil, T., Mushtaq, R., Yu, C., Sinha, S., Pollom, E. L., Nagpal, S., Camidge, D. R., Rusthoven, C. G., Braunstein, S. E., Wakelee, H. A., McCoach, C. E. 1800; 17 (2): e12-e14

    View details for DOI 10.1016/j.jtho.2021.11.017

    View details for PubMedID 35074229

  • 18F-FSPG PET/CT Imaging of System xC- Transporter Activity in Patients with Primary and Metastatic Brain Tumors. Radiology Wardak, M., Sonni, I., Fan, A. P., Minamimoto, R., Jamali, M., Hatami, N., Zaharchuk, G., Fischbein, N., Nagpal, S., Li, G., Koglin, N., Berndt, M., Bullich, S., Stephens, A. W., Dinkelborg, L. M., Abel, T., Manning, H. C., Rosenberg, J., Chin, F. T., Sam Gambhir, S., Mittra, E. S. 2022: 203296


    Background The PET tracer (4S)-4-(3-[18F]fluoropropyl)-l-glutamate (18F-FSPG) targets the system xC- cotransporter, which is overexpressed in various tumors. Purpose To assess the role of 18F-FSPG PET/CT in intracranial malignancies. Materials and Methods Twenty-six patients (mean age, 54 years ± 12; 17 men; 48 total lesions) with primary brain tumors (n = 17) or brain metastases (n = 9) were enrolled in this prospective, single-center study ( identifier: NCT02370563) between November 2014 and March 2016. A 30-minute dynamic brain 18F-FSPG PET/CT scan and a static whole-body (WB) 18F-FSPG PET/CT scan at 60-75 minutes were acquired. Moreover, all participants underwent MRI, and four participants underwent fluorine 18 (18F) fluorodeoxyglucose (FDG) PET imaging. PET parameters and their relative changes were obtained for all lesions. Kinetic modeling was used to estimate the 18F-FSPG tumor rate constants using the dynamic and dynamic plus WB PET data. Imaging parameters were correlated to lesion outcomes, as determined with follow-up MRI and/or pathologic examination. The Mann-Whitney U test or Student t test was used for group mean comparisons. Receiver operating characteristic curve analysis was used for performance comparison of different decision measures. Results 18F-FSPG PET/CT helped identify all 48 brain lesions. The mean tumor-to-background ratio (TBR) on the whole-brain PET images at the WB time point was 26.6 ± 24.9 (range: 2.6-150.3). When 18F-FDG PET was performed, 18F-FSPG permitted visualization of non-18F-FDG-avid lesions or allowed better lesion differentiation from surrounding tissues. In participants with primary brain tumors, the predictive accuracy of the relative changes in influx rate constant Ki and maximum standardized uptake value to discriminate between poor and good lesion outcomes were 89% and 81%, respectively. There were significant differences in the 18F-FSPG uptake curves of lesions with good versus poor outcomes in the primary brain tumor group (P < .05) but not in the brain metastases group. Conclusion PET/CT imaging with (4S)-4-(3-[18F]fluoropropyl)-l-glutamate (18F-FSPG) helped detect primary brain tumors and brain metastases with a high tumor-to-background ratio. Relative changes in 18F-FSPG uptake with multi-time-point PET appear to be helpful in predicting lesion outcomes. Clinical trial registration no. NCT02370563 © RSNA, 2022 Online supplemental material is available for this article.

    View details for DOI 10.1148/radiol.203296

    View details for PubMedID 35191738

  • Isolated Leptomeningeal Progression in a Patient with NTRK Fusion+ Uterine Sarcoma: A Case Report. Case reports in oncology Lanman, T., Hayden Gephart, M., Bui, N., Toland, A., Nagpal, S. 2021; 14 (3): 1841-1846


    While neurotrophic tropomyosin receptor kinase (NTRK) fusions represent rare oncogenic drivers (<1% of solid cancers), the recent approval of NTRK inhibitors (larotrectinib and entrectinib) led to dramatic responses in patients with NTRK fusion+ tumors. Both drugs have phase I data, demonstrating efficacy in the central nervous system (CNS), including both primary brain tumors and brain metastases. We present a 29-year-old woman who was diagnosed with NTRK3-SPECC1L fusion+ undifferentiated uterine sarcoma and underwent resection, chemotherapy, and radiotherapy. Two years later, lung metastases were discovered. She was started on larotrectinib with complete response. She remained stable on larotrectinib until she presented with altered mental status and seizures. MRI demonstrated leptomeningeal enhancement, but because leptomeningeal progression from sarcoma is exceedingly rare and her symptoms improved dramatically with antiepileptics, these findings were initially attributed to seizures. After 2 unrevealing lumbar punctures and stable systemic imaging, a brain biopsy demonstrated metastatic sarcoma, still showing NTRK positivity. She underwent whole brain radiotherapy and was switched to entrectinib, but had clinical progression 1 month later and transitioned to hospice. This case demonstrates the efficacy of NTRK inhibitors in rare and aggressive cancer but highlights that these patients can develop isolated CNS progression even in the setting of CNS-penetrant drugs. CNS progression can occur if there is incomplete CNS drug penetration, discordance in molecular profiles between CNS and systemic disease, or acquired NTRK inhibitor resistance. In this case, CNS disease maintained the NTRK fusion status, but either inadequate CNS penetration or development of a resistance gene may explain the isolated CNS progression.

    View details for DOI 10.1159/000521158

    View details for PubMedID 35111018

  • Management of complications from brain metastasis treatment: a narrative review. Chinese clinical oncology Diao, K., Sosa, A. J., Zada, G., Nagpal, S., Chang, E. L. 2021


    OBJECTIVE: To describe the range of potential side effects associated with modern brain metastasis treatment and provide evidenced-based guidance on the effective management of these side effects.BACKGROUND: Brain metastases are the most commonly diagnosed malignant intracranial tumor and have historically been associated with very poor prognosis. The standard treatment for brain metastases until the 1990s was whole-brain radiation therapy (WBRT) alone. Since then, however, numerous advances have established the role of neurosurgical resection, stereotactic radiosurgery (SRS), targeted systemic therapy, and immunotherapy in the multidisciplinary management of brain metastases and led to improvements in intracranial control, survival, and neurocognitive preservation among patients with brain metastases. As a result, however, brain metastasis treatment is associated with a wider range of potential side effects than ever before, and clinicians are tasked with the challenge of effectively managing these side effects without compromising cancer outcomes.METHODS: We performed a narrative review of peer-reviewed articles related to the management of side effects from multidisciplinary brain metastasis treatment and synthesized the data in the context of our clinical experience and practice.CONCLUSIONS: In this review, we summarize the major complications from intracranial radiotherapy, neurosurgical resection, and brain metastasis directed systemic therapy with corresponding evidenced-based, modern management principles to guide the practicing oncologist.

    View details for DOI 10.21037/cco-21-90

    View details for PubMedID 34670375

  • Comprehensive RNA analysis of CSF reveals a role for CEACAM6 in lung cancer leptomeningeal metastases. NPJ precision oncology Li, Y., Polyak, D., Lamsam, L., Connolly, I. D., Johnson, E., Khoeur, L. K., Andersen, S., Granucci, M., Stanley, G., Liu, B., Nagpal, S., Hayden Gephart, M. 2021; 5 (1): 90


    Non-small cell lung cancer (NSCLC) metastatic to the brain leptomeninges is rapidly fatal, cannot be biopsied, and cancer cells in the cerebrospinal fluid (CSF) are few; therefore, available tissue samples to develop effective treatments are severely limited. This study aimed to converge single-cell RNA-seq and cell-free RNA (cfRNA) analyses to both diagnose NSCLC leptomeningeal metastases (LM), and to use gene expression profiles to understand progression mechanisms of NSCLC in the brain leptomeninges. NSCLC patients with suspected LM underwent withdrawal of CSF via lumbar puncture. Four cytology-positive CSF samples underwent single-cell capture (n=197 cells) by microfluidic chip. Using robust principal component analyses, NSCLC LM cell gene expression was compared to immune cells. Massively parallel qPCR (9216 simultaneous reactions) on human CSF cfRNA samples compared the relative gene expression of patients with NSCLC LM (n=14) to non-tumor controls (n=7). The NSCLC-associated gene, CEACAM6, underwent in vitro validation in NSCLC cell lines for involvement in pathologic behaviors characteristic of LM. NSCLC LM gene expression revealed by single-cell RNA-seq was also reflected in CSF cfRNA of cytology-positive patients. Tumor-associated cfRNA (e.g., CEACAM6, MUC1) was present in NSCLC LM patients' CSF, but not in controls (CEACAM6 detection sensitivity 88.24% and specificity 100%). Cell migration in NSCLC cell lines was directly proportional to CEACAM6 expression, suggesting a role in disease progression. NSCLC-associated cfRNA is detectable in the CSF of patients with LM, and corresponds to the gene expression profile of NSCLC LM cells. CEACAM6 contributes significantly to NSCLC migration, a hallmark of LM pathophysiology.

    View details for DOI 10.1038/s41698-021-00228-6

    View details for PubMedID 34625644

  • American Radium Society Appropriate Use Criteria for the Management of Brain Metastases in EGFR-mutated Non-Small Cell Lung Cancer Nagpal, S., Chiang, V., Milano, M., Soltys, S., Ahluwalia, M., Chao, S., Garg, A., Gephart, M., Halasz, L., Jabbari, S., Knisely, J., Lo, S., Palmer, J., Sahgal, A., Tom, M., Wang, T., Chang, E. LIPPINCOTT WILLIAMS & WILKINS. 2021: S49-S50
  • American Radium Society's Appropriate Use Criteria on Postoperative Management of Lower Grade Gliomas Tom, M., Milano, M., Soltys, S., Sahgal, A., Knisely, J., Chiang, V., Nagpal, S., Lo, S., Chao, S., Jabbari, S., Wang, T., Palmer, J., Gephart, M., Garg, A., Ahluwalia, M., Halasz, L., Chang, E. LIPPINCOTT WILLIAMS & WILKINS. 2021: S51-S52
  • A Clinical PET Imaging Tracer ([18F]DASA-23) to Monitor Pyruvate Kinase M2 Induced Glycolytic Reprogramming in Glioblastoma. Clinical cancer research : an official journal of the American Association for Cancer Research Beinat, C., Patel, C. B., Haywood, T., Murty, S., Naya, L., Castillo, J. B., Reyes, S. T., Phillips, M., Buccino, P., Shen, B., Park, J. H., Koran, M. E., Alam, I. S., James, M. L., Holley, D., Halbert, K., Gandhi, H., He, J. Q., Granucci, M., Johnson, E., Liu, D. D., Uchida, N., Sinha, R., Chu, P., Born, D. E., Warnock, G. I., Weissman, I., Hayden Gephart, M., Khalighi, M. M., Massoud, T. F., Iagaru, A., Davidzon, G., Thomas, R., Nagpal, S., Recht, L. D., Gambhir, S. S. 2021


    PURPOSE: Pyruvate kinase M2 (PKM2) catalyzes the final step in glycolysis, a key process of cancer metabolism. PKM2 is preferentially expressed by glioblastoma (GBM) cells with minimal expression in healthy brain. We describe the development, validation, and translation of a novel positron emission tomography (PET) tracer to study PKM2 in GBM. We evaluated 1-((2-fluoro-6-[18F]fluorophenyl)sulfonyl)-4-((4-methoxyphenyl)sulfonyl)piperazine ([18F]DASA-23) in cell culture, mouse models of GBM, healthy human volunteers, and GBM patients.EXPERIMENTAL DESIGN: [18F]DASA-23 was synthesized with a molar activity of 100.47 {plus minus} 29.58 GBq/mol and radiochemical purity >95%. We performed initial testing of [18F]DASA-23 in GBM cell culture and human GBM xenografts implanted orthotopically into mice. Next we produced [18F]DASA-23 under FDA oversight, and evaluated it in healthy volunteers, and a pilot cohort of glioma patients.RESULTS: In mouse imaging studies, [18F]DASA-23 clearly delineated the U87 GBM from surrounding healthy brain tissue and had a tumor-to-brain ratio (TBR) of 3.6 {plus minus} 0.5. In human volunteers, [18F]DASA-23 crossed the intact blood-brain barrier and was rapidly cleared. In GBM patients, [18F]DASA-23 successfully outlined tumors visible on contrast-enhanced magnetic resonance imaging (MRI). The uptake of [18F]DASA-23 was markedly elevated in GBMs compared to normal brain, and it identified a metabolic non-responder within 1-week of treatment initiation.CONCLUSIONS: We developed and translated [18F]DASA-23 as a new tracer that demonstrated the visualization of aberrantly expressed PKM2 for the first time in human subjects. These results warrant further clinical evaluation of [18F]DASA-23 to assess its utility for imaging therapy-induced normalization of aberrant cancer metabolism.

    View details for DOI 10.1158/1078-0432.CCR-21-0544

    View details for PubMedID 34475101

  • Brain Metastases in EGFR- and ALK-positive Non-Small Cell Lung Cancer: Outcomes of CNS Penetrant Tyrosine Kinase Inhibitors (TKIs) Alone versus in Combination with Radiation. Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer Thomas, N. J., Myall, N. J., Sun, F., Patil, T., Mushtaq, R., Yu, C., Sinha, S., Pollom, E. L., Nagpal, S., Camidge, D. R., Rusthoven, C. G., Braunstein, S. E., Wakelee, H. A., McCoach, C. E. 2021


    INTRODUCTION: Management of central nervous system (CNS) metastases in patients with driver-mutated non-small cell lung cancer (NSCLC) has traditionally incorporated both tyrosine kinase inhibitors (TKIs) and intracranial radiation. Whether next-generation, CNS-penetrant TKIs can be used alone without upfront radiation, however, remains unknown. This multi-institutional retrospective analysis aimed to compare outcomes in patients with EGFR- or ALK-positive NSCLC who received CNS-penetrant TKI therapy alone versus in combination with radiation for new or progressing intracranial metastases.METHODS: Data was retrospectively collected from 3 academic institutions. Two treatment groups (CNS-penetrant TKI alone vs TKI+CNS RT) were compared for both EGFR- and ALK-positive cohorts. Outcome variables included time to progression, time to intracranial progression, and time to treatment failure, measured from the date of initiation of CNS-penetrant TKI therapy.RESULTS: A total of 147 patients were included (EGFR n=94, ALK n=52, both n=1). In patients receiving radiation, larger metastases, neurological symptoms, and receipt of steroids were more common. There were no significant differences between TKI vs CNS RT+TKI groups for any of the study outcomes, including time to progression (8.5 vs 6.9 months, p=0.13 [EFGR] and 11.4 vs 13.4 months, p=0.98 [ALK]), time to intracranial progression (14.8 vs 20.5 months, p=0.51 [EGFR] and 18.1 vs 21.8 months, p=0.65 [ALK]), or time to treatment failure (13.8 vs 8.6 months, p=0.26 [EGFR] and 13.5 vs 23.2 months, p=0.95 [ALK]).CONCLUSION: These results provide preliminary evidence that intracranial activity of CNS-penetrant TKIs may enable local radiation to be deferred in appropriately selected patients without negatively impacting progression.

    View details for DOI 10.1016/j.jtho.2021.08.009

    View details for PubMedID 34455066

  • EF-32 (TRIDENT): A pivotal randomized trial of radiation therapy concomitant with temozolomide plus /- Tumor Treating Fields (TTFields) in newly diagnosed glioblastoma. Shi, W., Kleinberg, L., Jeyapalan, S. A., Goldlust, S. A., Nagpal, S., Combs, S. E., Roberge, D., Nishigawa, R., Grossman, R., Glas, M. AMER ASSOC CANCER RESEARCH. 2021
  • EGFR-targeted intraoperative fluorescence imaging detects high-grade glioma with panitumumab-IRDye800 in a phase 1 clinical trial. Theranostics Zhou, Q., van den Berg, N. S., Rosenthal, E. L., Iv, M., Zhang, M., Vega Leonel, J. C., Walters, S., Nishio, N., Granucci, M., Raymundo, R., Yi, G., Vogel, H., Cayrol, R., Lee, Y. J., Lu, G., Hom, M., Kang, W., Hayden Gephart, M., Recht, L., Nagpal, S., Thomas, R., Patel, C., Grant, G. A., Li, G. 2021; 11 (15): 7130-7143


    Rationale: First-line therapy for high-grade gliomas (HGGs) includes maximal safe surgical resection. The extent of resection predicts overall survival, but current neuroimaging approaches lack tumor specificity. The epidermal growth factor receptor (EGFR) is a highly expressed HGG biomarker. We evaluated the safety and feasibility of an anti-EGFR antibody, panitumuab-IRDye800, at subtherapeutic doses as an imaging agent for HGG. Methods: Eleven patients with contrast-enhancing HGGs were systemically infused with panitumumab-IRDye800 at a low (50 mg) or high (100 mg) dose 1-5 days before surgery. Near-infrared fluorescence imaging was performed intraoperatively and ex vivo, to identify the optimal tumor-to-background ratio by comparing mean fluorescence intensities of tumor and histologically uninvolved tissue. Fluorescence was correlated with preoperative T1 contrast, tumor size, EGFR expression and other biomarkers. Results: No adverse events were attributed to panitumumab-IRDye800. Tumor fragments as small as 5 mg could be detected ex vivo and detection threshold was dose dependent. In tissue sections, panitumumab-IRDye800 was highly sensitive (95%) and specific (96%) for pathology confirmed tumor containing tissue. Cellular delivery of panitumumab-IRDye800 was correlated to EGFR overexpression and compromised blood-brain barrier in HGG, while normal brain tissue showed minimal fluorescence. Intraoperative fluorescence improved optical contrast in tumor tissue within and beyond the T1 contrast-enhancing margin, with contrast-to-noise ratios of 9.5 ± 2.1 and 3.6 ± 1.1, respectively. Conclusions: Panitumumab-IRDye800 provided excellent tumor contrast and was safe at both doses. Smaller fragments of tumor could be detected at the 100 mg dose and thus more suitable for intraoperative imaging.

    View details for DOI 10.7150/thno.60582

    View details for PubMedID 34158840

    View details for PubMedCentralID PMC8210618

  • Comprehensive molecular pharmacodynamic assessment identifies response markers of intermediary metabolism associated with BPM 31510-IV treatment in advanced glioblastoma multiforme patients. Nagpal, S., Sarangarajan, R., Bruce, C., Miller, G. M., Rodrigues, L. O., Shah, P., Searfoss, R., Ofori-Mensa, K., Tolstikov, V., Greenwood, B., Bussberg, V., Kiebish, M. A., Granger, E., Narain, N. R., Recht, L. LIPPINCOTT WILLIAMS & WILKINS. 2021
  • A Case of Isolated Leptomeningeal Progression in a Patient with NTRK Fusion plus Uterine Sarcoma Lanman, T., Hayden, M., Bui, N., Nagpal, S. LIPPINCOTT WILLIAMS & WILKINS. 2021
  • Impact of Low-Dose CT Screening for Primary Lung Cancer on Subsequent Risk of Brain Metastasis. Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer Su, C. C., Wu, J. T., Neal, J. W., Popat, R. A., Kurian, A. W., Backhus, L. M., Nagpal, S., Leung, A. N., Wakelee, H. A., Han, S. S. 2021


    Brain metastasis (BM) is one of the most common metastases from primary lung cancer (PLC). Recently, the National Lung Screening Trial (NLST) demonstrated the efficacy of low-dose computed tomography (LDCT) screening on LC mortality reduction. However, it remains unknown if early detection of PLC through LDCT may be potentially beneficial in reducing the risk of subsequent metastases. Our study aimed to investigate the impact of LDCT screening for PLC on the risk of developing BM after PLC diagnosis.We used NLST data to identify 1,502 participants who were diagnosed with PLC in 2002-2009 and have follow-up data for BM. Cause-specific competing risk regression was applied to evaluate an association between BM risk and the mode of PLC detection-i.e., LDCT screen-detected versus non-LDCT screen-detected. Subgroup analyses were conducted in early-stage PLC patients and those who underwent surgery for PLC.Of 1502 participants, 41.4% had PLC detected through LDCT-screening versus 58.6% detected through other methods, e.g., chest X-Ray or incidental detection. Patients whose PLC was detected with LDCT-screening had a significantly lower 3-year incidence of BM (6.5%) versus those without (11.9%), with a cause-specific hazard ratio (HR) of 0.53 (p=0.001), adjusting for PLC stage, histology, diagnosis age and smoking status. This significant reduction in BM risk among PLCs detected through LDCT-screening persisted in subgroups of early-stage PLC participants (HR 0.47, p=0.002) and those who underwent surgery (HR 0.37, p=0.001).Early detection of PLC using LDCT-screening is associated with lower risk of BM after PLC diagnosis based on a large population-based study.

    View details for DOI 10.1016/j.jtho.2021.05.010

    View details for PubMedID 34091050

  • Neuro-Oncology Practice Clinical Debate: long-term antiepileptic drug prophylaxis in patients with glioma. Neuro-oncology practice Stocksdale, B., Nagpal, S., Hixson, J. D., Johnson, D. R., Rai, P., Shivaprasad, A., Tremont-Lukats, I. W. 2020; 7 (6): 583–88


    Patients with primary brain tumors often experience seizures, which can be the presenting symptom or occur for the first time at any point along the illness trajectory. In addition to causing morbidity, seizures negatively affect independence and quality of life in other ways, for example, by leading to loss of driving privileges. Long-term therapy with antiepileptic drugs (AEDs) is the standard of care in brain tumor patients with seizures, but the role of prophylactic AEDs in seizure-naive patients remains controversial. In this article, experts in the field discuss the issues of AED efficacy and toxicity, and explain their differing recommendations for routine use of prophylactic AEDs.

    View details for DOI 10.1093/nop/npaa026

    View details for PubMedID 33312673

  • Seven decades of chemotherapy clinical trials: a pan-cancer social network analysis. Scientific reports Li, X., Sigworth, E. A., Wu, A. H., Behrens, J., Etemad, S. A., Nagpal, S., Go, R. S., Wuichet, K., Chen, E. J., Rubinstein, S. M., Venepalli, N. K., Tillman, B. F., Cowan, A. J., Schoen, M. W., Malty, A., Greer, J. P., Fernandes, H. D., Seifter, A., Chen, Q., Chowdhery, R. A., Mohan, S. R., Dewdney, S. B., Osterman, T., Ambinder, E. P., Buchbinder, E. I., Schwartz, C., Abraham, I., Rioth, M. J., Singh, N., Sharma, S., Gibson, M. K., Yang, P. C., Warner, J. L. 2020; 10 (1): 17536


    Clinical trials establish the standard of cancer care, yet the evolution and characteristics of the social dynamics between the people conducting this work remain understudied. We performed a social network analysis of authors publishing chemotherapy-based prospective trials from 1946 to 2018 to understand how social influences, including the role of gender, have influenced the growth and development of this network, which has expanded exponentially from fewer than 50 authors in 1946 to 29,197 in 2018. While 99.4% of authors were directly or indirectly connected by 2018, our results indicate a tendency to predominantly connect with others in the same or similar fields, as well as an increasing disparity in author impact and number of connections. Scale-free effects were evident, with small numbers of individuals having disproportionate impact. Women were under-represented and likelier to have lower impact, shorter productive periods (P<0.001 for both comparisons), less centrality, and a greater proportion of co-authors in their same subspecialty. The past 30years were characterized by a trend towards increased authorship by women, with new author parity anticipated in 2032. The network of cancer clinical trialists is best characterized as strategic or mixed-motive, with cooperative and competitive elements influencing its appearance. Network effects such as low centrality, which may limit access to high-profile individuals, likely contribute to the observed disparities.

    View details for DOI 10.1038/s41598-020-73466-6

    View details for PubMedID 33067482

  • Report from the American Radium Society (ARS) Appropriate Use Criteria Brain Malignancies Panel: Treatment of Multiple Brain Metastases Milano, M., Chiang, V., Soltys, S., Wang, T., Lo, S., Brackett, A., Gephart, M., Nagpal, S., Jabbari, S., Halasz, L., Chao, S., Garg, A., Knisely, J., Sahgal, A., Chang, E. ELSEVIER SCIENCE INC. 2020: E27–E28
  • High levels of ubidecarenone (oxidized CoQ10) delivered using a drug-lipid conjugate nanodispersion (BPM31510) differentially affect redox status and growth in malignant glioma versus non-tumor cells. Scientific reports Sun, J., Patel, C. B., Jang, T., Merchant, M., Chen, C., Kazerounian, S., Diers, A. R., Kiebish, M. A., Vishnudas, V. K., Gesta, S., Sarangarajan, R., Narain, N. R., Nagpal, S., Recht, L. 2020; 10 (1): 13899


    Metabolic reprogramming in cancer cells, vs. non-cancer cells, elevates levels of reactive oxygen species (ROS) leading to higher oxidative stress. The elevated ROS levels suggest a vulnerability to excess prooxidant loads leading to selective cell death, a therapeutically exploitable difference. Co-enzyme Q10 (CoQ10) an endogenous mitochondrial resident molecule, plays an important role in mitochondrial redox homeostasis, membrane integrity, and energy production. BPM31510 is a lipid-drug conjugate nanodispersion specifically formulated for delivery of supraphysiological concentrations of ubidecarenone (oxidized CoQ10) to the cell and mitochondria, in both in vitro and in vivo model systems. In this study, we sought to investigate the therapeutic potential of ubidecarenone in the highly treatment-refractory glioblastoma. Rodent (C6) and human (U251) glioma cell lines, and non-tumor human astrocytes (HA) and rodent NIH3T3 fibroblast cell lines were utilized for experiments. Tumor cell lines exhibited a marked increase in sensitivity to ubidecarenone vs. non-tumor cell lines. Further, elevated mitochondrial superoxide production was noted in tumor cells vs. non-tumor cells hours before any changes in proliferation or the cell cycle could be detected. In vitro co-culture experiments show ubidecarenone differentially affecting tumor cells vs. non-tumor cells, resulting in an equilibrated culture. In vivo activity in a highly aggressive orthotopic C6 glioma model demonstrated a greater than 25% long-term survival rate. Based on these findings we conclude that high levels of ubidecarenone delivered using BPM31510 provide an effective therapeutic modality targeting cancer-specific modulation of redox mechanisms for anti-cancer effects.

    View details for DOI 10.1038/s41598-020-70969-0

    View details for PubMedID 32807842

  • BPM31510, a Coenzyme Q10 (CoQ10) containing lipid nanodispersion, enhances radiation effects to prolong survival in a rodent glioblastoma model Sun, J., Merchant, M., Diers, A. R., Kazerounian, S., Gesta, S., Narain, N. R., Sarangarajan, R., Nagpal, S., Recht, L. AMER ASSOC CANCER RESEARCH. 2020
  • INO-5401 and INO-9012 delivered intramuscularly (IM) with electroporation (EP) in combination with cemiplimab (REGN2810) in newly diagnosed glioblastoma (GBM): Interim results. Reardon, D. A., Brem, S., Desai, A., Bagley, S., Kurz, S., De La Fuente, M., Nagpal, S., Welch, M., Hormigo, A., Carroll, N., Bartra, S. K., Campbell, P., Bhatt, K., Lowy, I., Boyer, J., Kraynyak, K., Morrow, M. P., McMullan, T., Weiner, D. B., Skolnik, J. AMER SOC CLINICAL ONCOLOGY. 2020
  • Phase I study of BPM31510 and vitamin K in patients with high grade glioma recurrent after a bevacizumab-containing regimen. Nagpal, S., Thomas, R., Bertrand, S., Yerraballa, H., Iv, M., Li, G., Klotz, A., Kiebish, M. A., Narain, N. R., Sarangarajan, R., Granger, E., Recht, L. AMER SOC CLINICAL ONCOLOGY. 2020
  • AN OPEN-LABEL, MULTI-CENTER TRIAL OF INO-5401 AND INO-9012 DELIVERED BY ELECTROPORATION (EP) IN COMBINATION WITH CEMIPLIMAB IN SUBJECTS WITH NEWLY-DIAGNOSED GLIOBLASTOMA (GBM) Skolnik, J., Reardon, D., Brem, S., Desai, A., Bagley, S., Kurz, S., de la Fuente, M., Nagpal, S., Welch, M., Sacchetta, B., Bartra, S., Bredlau, A., Lowy, I., Kraynyak, K., Morrow, M., McMullan, T., Boyer, J. BMJ PUBLISHING GROUP. 2020: A8

    View details for DOI 10.1136/LBA2019.12

    View details for Web of Science ID 000540356400013

  • Stereotactic Radiosurgery After Resection of Brain Metastases: Changing Patterns of Care in the United States. World neurosurgery Chin, A. L., Li, G. n., Gephart, M. H., Sandhu, N. n., Nagpal, S. n., Soltys, S. G., Pollom, E. L. 2020


    Management of symptomatic brain metastases often includes surgical resection with postoperative radiotherapy. Postoperative whole brain radiotherapy (WBRT) improves intracranial control but detrimentally impacts quality of life and neurocognition. We sought to characterize the use in the United States of postoperative stereotactic radiosurgery (SRS), an evolving standard-of-care associated with reduced cognitive effects.With the MarketScan Commercial Claims and Encounters Database from 2007 to 2015, we identified patients aged 18-65 years treated with resection of a brain metastasis followed by SRS or WBRT within 60 days of surgery. Logistic regression estimated associations between co-variables (treatment year, age, sex, geographic region, place of service, insurance type, disease histology, comorbidity score, and median area household income and educational attainment) and SRS receipt.Of 4,007 patients included, 1,506 (37.6%) received SRS and 2,501 (62.4%) received WBRT. Postoperative SRS increased from 16.5% (2007-2008) to 56.8% (2014-2015). Patients residing in areas with a median household income or an educational attainment below 50th percentile were significantly less likely to receive SRS after controlling for treatment year and other demographic characteristics (p<0.01). Factors associated with higher odds of receiving SRS included younger age, female sex, melanoma histology, Western region location, hospital-based facility, and high-deductible health plan enrollment (p<0.05 for each).Postoperative SRS for brain metastases has increased from 2007 to 2015, with the majority of patients now receiving SRS over WBRT. Patients in areas of lower socioeconomic class were less likely to receive SRS, warranting further investigation of barriers to SRS adoption.

    View details for DOI 10.1016/j.wneu.2020.09.085

    View details for PubMedID 32971279

  • Central Nervous System Cancers, Version 3.2020, NCCN Clinical Practice Guidelines in Oncology. Journal of the National Comprehensive Cancer Network : JNCCN Nabors, L. B., Portnow, J., Ahluwalia, M., Baehring, J., Brem, H., Brem, S., Butowski, N., Campian, J. L., Clark, S. W., Fabiano, A. J., Forsyth, P., Hattangadi-Gluth, J., Holdhoff, M., Horbinski, C., Junck, L., Kaley, T., Kumthekar, P., Loeffler, J. S., Mrugala, M. M., Nagpal, S., Pandey, M., Parney, I., Peters, K., Puduvalli, V. K., Robins, I., Rockhill, J., Rusthoven, C., Shonka, N., Shrieve, D. C., Swinnen, L. J., Weiss, S., Wen, P. Y., Willmarth, N. E., Bergman, M. A., Darlow, S. D. 2020; 18 (11): 1537–70


    The NCCN Guidelines for Central Nervous System (CNS) Cancers focus on management of adult CNS cancers ranging from noninvasive and surgically curable pilocytic astrocytomas to metastatic brain disease. The involvement of an interdisciplinary team, including neurosurgeons, radiation therapists, oncologists, neurologists, and neuroradiologists, is a key factor in the appropriate management of CNS cancers. Integrated histopathologic and molecular characterization of brain tumors such as gliomas should be standard practice. This article describes NCCN Guidelines recommendations for WHO grade I, II, III, and IV gliomas. Treatment of brain metastases, the most common intracranial tumors in adults, is also described.

    View details for DOI 10.6004/jnccn.2020.0052

    View details for PubMedID 33152694

  • Executive Summary from American Radium Society's Appropriate Use Criteria on Neurocognition after stereotactic radiosurgery for multiple brain metastases. Neuro-oncology Milano, M. T., Chiang, V. L., Soltys, S. G., Wang, T. J., Lo, S. S., Brackett, A. n., Nagpal, S. n., Chao, S. n., Garg, A. K., Jabbari, S. n., Halasz, L. M., Gephart, M. H., Knisely, J. P., Sahgal, A. n., Chang, E. L. 2020


    The ARS Appropriate Use Criteria brain malignancies panel systematically reviewed (PRISMA) published literature on neurocognitive outcomes after stereotactic radiosurgery (SRS) for patients with multiple brain metastases (BrM) to generate consensus guidelines.The panel developed 4 key questions (KQ) to guide systematic review. From 11,614 original articles, 12 were selected. The panel developed model cases addressing KQ and potentially controversial scenarios not addressed in the systematic review (that might inform future ARS projects). Based upon quality of evidence, the panel confidentially voted on treatment options using a 9-point scale of appropriateness.The panel agreed that SRS-alone is usually appropriate for those with good performance status (PS) and 2-10 asymptomatic BrM, and usually not appropriate for >20 BrM. For 11-15 and 16-20 BrM there was (between 4 case variants) agreement that SRS-alone may be appropriate or disagreement on the appropriateness of SRS-alone. There was no scenario in which conventional whole brain radiotherapy (WBRT) was considered usually appropriate by most panelists. There were several areas of disagreement, including: hippocampal sparing WBRT for 2-4 asymptomatic BrM; WBRT for resected BrM amenable to SRS; fractionated- vs, single-fraction SRS for resected BrM, larger targets and/or brainstem metastases; optimal treatment (WBRT, hippocampal sparing WBRT, SRS-alone to all or select lesions) for patients with progressive extracranial disease, poor PS and no systemic options.For patients with 2-10 BrM, SRS-alone is an appropriate treatment option for well-selected patients with good PS. Future study is needed for those scenarios in which there was disagreement among panelists.

    View details for DOI 10.1093/neuonc/noaa192

    View details for PubMedID 32780818

  • Rapid Fluctuation of Subretinal Fluid on Encorafenib and Binimetinib. Retina (Philadelphia, Pa.) Li, A. S., Leng, T. n., Nagpal, S. n., Liao, Y. J. 2020

    View details for DOI 10.1097/IAE.0000000000002965

    View details for PubMedID 32833784

  • Evaluating Surgical Resection Extent and Adjuvant Therapy in the Management of Gliosarcoma. Frontiers in oncology Jin, M. C., Liu, E. K., Shi, S. n., Gibbs, I. C., Thomas, R. n., Recht, L. n., Soltys, S. G., Pollom, E. L., Chang, S. D., Hayden Gephart, M. n., Nagpal, S. n., Li, G. n. 2020; 10: 337


    Introduction: Gliosarcomas are clinically aggressive tumors, histologically distinct from glioblastoma. Data regarding the impact of extent of resection and post-operative adjuvant therapy on gliosarcoma outcomes are limited. Methods: Patients with histologically confirmed gliosarcoma diagnosed between 1999 and 2019 were identified. Clinical, molecular, and radiographic data were assembled based on historical records. Comparisons of categorical variables used Pearson's Chi-square and Fisher's exact test while continuous values were compared using the Wilcoxon signed-rank test. Survival comparisons were assessed using Kaplan-Meier statistics and Cox regressions. Results: Seventy-one gliosarcoma patients were identified. Secondary gliosarcoma was not associated with worse survival when compared to recurrent primary gliosarcoma (median survival 9.8 [3.8 to 21.0] months vs. 7.6 [1.0 to 35.7], p = 0.7493). On multivariable analysis, receipt of temozolomide (HR = 0.02, 95% CI 0.001-0.21) and achievement of gross total resection (GTR; HR = 0.13, 95% CI 0.02-0.77) were independently prognostic for improved progression-free survival (PFS) while only receipt of temozolomide was independently associated with extended overall survival (OS) (HR = 0.03, 95% CI 0.001-0.89). In patients receiving surgical resection followed by radiotherapy and concomitant temozolomide, achievement of GTR was significantly associated with improved PFS (median 32.97 [7.1-79.6] months vs. 5.45 [1.8-26.3], p = 0.0092) and OS (median 56.73 months [7.8-104.5] vs. 14.83 [3.8 to 29.1], p = 0.0252). Conclusion: Multimodal therapy is associated with improved survival in gliosarcoma. Even in patients receiving aggressive post-operative multimodal management, total surgical removal of macroscopic disease remains important for optimal outcomes.

    View details for DOI 10.3389/fonc.2020.00337

    View details for PubMedID 32219069

    View details for PubMedCentralID PMC7078164

  • A Phase I/II Trial of 5-Fraction Stereotactic Radiosurgery with 5-mm Margins with Concurrent Temozolomide in Newly Diagnosed Glioblastoma: Primary Outcomes. Neuro-oncology Azoulay, M. n., Chang, S. D., Gibbs, I. C., Hancock, S. L., Pollom, E. L., Harsh, G. R., Adler, J. R., Harrahar, C. n., Li, G. n., Hayden Gephart, M. n., Nagpal, S. n., Thomas, R. P., Recht, L. D., Jacobs, L. R., Modlin, L. A., Wynne, J. n., Seiger, K. n., Fujimoto, D. n., Usoz, M. n., von Eyben, R. n., Choi, C. Y., Soltys, S. G. 2020


    We sought to determine the maximum tolerated dose (MTD) of 5-fraction stereotactic radiosurgery (SRS) with 5-mm margins delivered with concurrent temozolomide in newly diagnosed glioblastoma.We enrolled adult patients with newly diagnosed glioblastoma to 5 days of SRS in a 3+3 design on 4 escalating dose levels: 25, 30, 35, and 40 Gy. Dose limiting toxicity (DLT) was defined as CTCAE Grade 3-5 acute or late CNS toxicity, including adverse radiation effect (ARE), the imaging correlate of radiation necrosis.From 2010 to 2015, 30 patients were enrolled. The median age was 66 years (range 51-86 years). The median target volume was 60 cm3 (range 14.7-137.3 cm3). DLT occurred in 2 patients: one for post-treatment cerebral edema and progressive disease at 3 weeks (Grade 4, Dose 40 Gy); another patient died 1.5 weeks following SRS from post-operative complications (Grade 5, Dose 40 Gy). Late grade 1-2 ARE occurred in 8 patients at a median of 7.6 months (range 3.2-12.6 months). No grade 3-5 ARE occurred. With a median follow-up of 13.8 months (range 1.7-64.4 months), the median survival times were: PFS 8.2 months (95%CI 4.6-10.5), OS 14.8 months (95%CI 10.9-19.9), MGMT hypermethylated 19.9 months (95%CI 10.5-33.5) vs. 11.3 months (95%CI 8.9-17.6) for no/unknown hypermethylation (p=0.03), and 27.2 months (95%CI 11.2-48.3) if late ARE occurred vs. 11.7 months (95%CI 8.9-17.6) for no ARE (p=0.08).The per-protocol MTD of 5-fraction SRS with 5-mm margins with concurrent temozolomide was 40 Gy in 5 fractions. ARE was limited to grade 1-2 and did not statistically impact survival.

    View details for DOI 10.1093/neuonc/noaa019

    View details for PubMedID 32002547

  • Macrophage exclusion after radiation therapy (MERT): A new and effective way to increase the therapeutic ratio of radiotherapy. Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology Brown, J. M., Thomas, R., Nagpal, S., Recht, L. 2019; 144: 159–64


    Here we review a variety of preclinical studies and a first-in-human clinical trial of newly diagnosed glioblastoma (GBM) patients that have investigated the significance of the influx of tumor associated macrophages (TAMs) into tumors after irradiation. We summarize the effects on the response of the tumors and normal tissues to radiation of various agents that either reduce the influx of TAMs into tumors after radiation or change their M1/M2 polarization. The studies show that following irradiation there is an accumulation of bone marrow derived TAMs in the irradiated tumors. These TAMs stimulate the resumption of blood flow in the irradiated tumors thereby promoting recurrence of the tumors. A key mechanism for this accumulation of TAMs is driven by the SDF-1/CXCR4 chemokine pathway though other pathways could also be involved for some tumors. Blocking this pathway to prevent the TAM accumulation in the tumors both enhances tumor response to radiation and protects irradiated tissues. A clinical trial in which the CXCR4 antagonist plerixafor was added to standard therapy of glioblastoma validated the preclinical findings by demonstrating i) reduced blood flow in the irradiated site, and ii) significantly improved tumor local control compared to GBM patients not treated with plerixafor. We conclude that macrophage exclusion after radiation therapy (MERT) is an effective way both to enhance the tumor response to radiation and to protect the irradiated normal tissues. Further clinical trials are warranted.

    View details for DOI 10.1016/j.radonc.2019.11.020

    View details for PubMedID 31812931

  • EVALUATION OF DYNAMIN 2 (DNM2) AS A THERAPEUTIC TARGET IN LEPTOMENINGEAL METASTATIC DISEASE Chernikova, S., Polyak, D., Deng, J., Tsau, S., Casey, K., Johnson, E., Bhambhvani, H., Khoeur, L., Stanley, G., Tran, K., Connolly, I., Joyce, A., Li, Y., von Eyben, R., Nagpal, S., Gephart, M. OXFORD UNIV PRESS INC. 2019: 57
  • TOCA 511 & TOCA FC VERSUS STANDARD OF CARE IN PATIENTS WITH RECURRENT HIGH GRADE GLIOMA Cloughesy, T., Petrecca, K., Walbert, T., Butowski, N., Salacz, M., Perry, J., Damek, D., Bota, D., Bettegowda, C., Zhu, J., Iwamoto, F., Placantonakis, D., Martinez, N., Elder, J., Kaptain, G., Cachia, D., Moshel, Y., Brem, S., Picconi, D., Nam Tran, Nam, D., Park, C., Landolfi, J., Tran, D., Ramakrishna, R., Fink, K., Heros, D., Zadeh, G., Nicholas, G., Mehta, V., Robins, H., Chen, C., Pitz, M., Heth, J., Nagpal, S., Pearlman, M., Ahluwalia, M., Mohile, N., Merrell, R., Schiff, D., Thompson, R., Davis, R., Macdonald, D., Kheoh, T., Kabbinavar, F., Lossos, A., Vogelbaum, M. OXFORD UNIV PRESS INC. 2019: 284
  • A PHASE 1 STUDY OF BPM31510 PLUS VITAMIN K IN SUBJECTS WITH HIGH-GRADE GLIOMA THAT HAS RECURRED ON A BEVACIZUMAB-CONTAINING REGIMEN Recht, L., Thomas, R., Bertrand, S., Yerballa, P., Li, G., Iv, M., Narain, N., Sarangarajan, R., Granger, E., Nagpal, S. OXFORD UNIV PRESS INC. 2019: 27
  • EVALUATION OF [18F]DASA-23 FOR NON-INVASIVE MEASUREMENT OF ABERRANTLY EXPRESSED PYRUVATE KINASE M2 IN GLIOMA: FIRST-IN-HUMAN STUDY Patel, C., Beinat, C., Haywood, T., Murty, S., Xie, Y., Recht, L., Nagpal, S., Thomas, R., Khalighi, M., Gandhi, H., Holley, D., Gambhir, S. OXFORD UNIV PRESS INC. 2019: 169
  • Professor Seema Nagpal: which one should be given the priority, radiation or drug? ANNALS OF TRANSLATIONAL MEDICINE Zhou, M., Zhou, A., Nagpal, S. 2019; 7 (22)
  • COMPREHENSIVE RNA ANALYSIS OF CEREBROSPINAL FLUID FROM LEPTOMENINGEAL METASTASES Polyak, D., Li, Y., Liu, B., Connolly, I., Khoeur, L., Kakusa, B., Johnson, E., Andersen, S., Pan, W., Nagpal, S., Montgomery, S. B., Gephart, M. OXFORD UNIV PRESS INC. 2019: 62
  • BPM31510 exploits differential redox vulnerabilities between normal and glioblastoma cells to mediate its anti-cancer effect Sun, J., Nagpal, S., Patel, C., Merchant, M., Jang, T., Diers, A. R., Kazerounian, S., Gesta, S., Narain, N. R., Sarangarajan, R., Recht, L. AMER ASSOC CANCER RESEARCH. 2019
  • Osimertinib for EGFR-Mutant Lung Cancer with Brain Metastases: Results from a Single-Center Retrospective Study ONCOLOGIST Xie, L., Nagpal, S., Wakelee, H. A., Li, G., Soltys, S. G., Neal, J. W. 2019; 24 (6): 836–43
  • Adverse Radiation Effect and Disease Control in Patients Undergoing Stereotactic Radiosurgery and Immune Checkpoint Inhibitor Therapy for Brain Metastases WORLD NEUROSURGERY Koenig, J. L., Shi, S., Sborov, K., Gensheimer, M. F., Le, G., Nagpal, S., Chang, S. D., Gibbs, I. C., Soltys, S. G., Pollom, E. L. 2019; 126: E1399–E1411
  • To Biopsy or Not to Biopsy? A case of primary intramedullary spinal cord lymphoma presenting as longitudinally extensive transverse myelitis within cervical cord Satyanarayan, S., Rizvi, A., Nagpal, S. LIPPINCOTT WILLIAMS & WILKINS. 2019
  • Adverse Radiation Effect and Disease Control in Patients Undergoing Stereotactic Radiosurgery and Immune Checkpoint Inhibitor Therapy for Brain Metastases. World neurosurgery Koenig, J. L., Shi, S., Sborov, K., Gensheimer, M. F., Li, G., Nagpal, S., Chang, S. D., Gibbs, I. C., Soltys, S. G., Pollom, E. L. 2019


    BACKGROUND: Immune checkpoint inhibitors (ICIs) and stereotactic radiosurgery (SRS) are increasingly used together to manage brain metastases (BMs). We assessed adverse radiation effect, disease control, and overall survival in patients with BMs who received SRS with anti-CTLA-4 and/or anti-PD-1/PD-L1 therapies.METHODS: We retrospectively reviewed the records of patients with intact or resected BMs treated with SRS and ICIs within 5 months of SRS between 2010 and 2018. Patients were defined as receiving 'concurrent' SRS and ICI if a dose of ICI was given within 4 weeks of SRS. Local failure (LF), distant intracranial failure (DIF), extracranial failure (EF), and adverse radiation effect (ARE) were assessed using cumulative incidence rates and competing risk regressions with death as a competing risk. Overall survival was assessed using the Kaplan-Meier method and Cox proportional hazards models.RESULTS: A total of 97 patients with 580 BMs were included in our analysis. Competing risk analyses demonstrated that concurrent SRS-ICI therapy is associated with higher rates of ARE (6.4% vs 2.0% at 1 year; multivariable HR 4.47; 95% CI, 1.57-12.73; p=0.005), lower rates of EF (69.7% vs 80.8% at 1 year; multivariable HR 0.60; 95% CI, 0.42-0.87; p=0.007), and better overall survival (48.6% vs 25.4% at 1 year; multivariable HR 0.57; 95% CI, 0.33-0.99; p=0.044) as compared to non-concurrent therapy. SRS-ICI timing was not associated with LF or DIF.CONCLUSIONS: Concurrent SRS-ICI therapy has a tolerable adverse event profile and may improve extracranial disease control and overall survival, supporting concurrent use in the management of BMs.

    View details for PubMedID 30902777

  • Current State of Immunotherapy for Treatment of Glioblastoma. Current treatment options in oncology McGranahan, T., Therkelsen, K. E., Ahmad, S., Nagpal, S. 2019; 20 (3): 24


    OPINION STATEMENT: At this time, there are no FDA-approved immune therapies for glioblastoma (GBM) despite many unique therapies currently in clinical trials. GBM is a highly immunosuppressive tumor and there are limitations to a safe immune response in the central nervous system. To date, there have been several failures of phase 3 immune therapy clinical trials in GBM. These trials have targeted single components of an antitumor immune response. Learning from these failures, the future of immunotherapy for GBM appears most hopeful for combination of immune therapies to overcome the profound immunosuppression of this disease. Understanding biomarkers for appropriate patient selection as well as tumor progression are necessary for implementation of immunotherapy for GBM.

    View details for PubMedID 30790064

  • Nodular Leptomeningeal Disease - A Distinct Pattern of Recurrence After Post-Resection Stereotactic Radiosurgery for Brain Metastases: A Multi-Institutional Study of Inter-Observer Reliability. International journal of radiation oncology, biology, physics Turner, B. E., Prabhu, R. S., Burri, S. H., Brown, P. D., Pollom, E. L., Milano, M. T., Weiss, S. E., Iv, M. n., Fischbein, N. n., Soliman, H. n., Lo, S. S., Chao, S. T., Cox, B. W., Murphy, J. D., Li, G. n., Gephart, M. H., Nagpal, S. n., Atalar, B. n., Azoulay, M. n., Thomas, R. n., Tillman, G. n., Durkee, B. Y., Shah, J. L., Soltys, S. G. 2019


    For brain metastases, surgical resection with postoperative stereotactic radiosurgery (SRS) is an emerging standard of care. Postoperative cavity SRS is associated with a specific, under-recognized pattern of intracranial recurrence, herein termed nodular leptomeningeal disease (nLMD), which is distinct from classical leptomeningeal disease (cLMD). We hypothesized that there is poor consensus regarding the definition of LMD, and that a formal, self-guided training module will improve inter-rater reliability (IRR) and validity in diagnosing LMD.Twenty-two physicians at 16 institutions, including 15 physicians with central nervous system (CNS) expertise, completed a two-phase survey that included MRI imaging and treatment information for 30 patients. In the "pre-training" phase, physicians labeled cases using 3 patterns of recurrence commonly reported in prospective studies: local recurrence (LR), distant parenchymal recurrence (DR), and LMD. After a self-directed training module, participating physicians completed the "post-training" phase and relabeled the 30 cases using the 4 following labels: LR, DR, cLMD, nLMD.Inter-rater reliability (IRR) increased 34% after training (Fleiss' Kappa K=0.41 to K=0.55, p<0.001). IRR increased most among non-CNS specialists (+58%, p<0.001). Prior to training, IRR was lowest for LMD (K=0.33). After training, IRR increased across all recurrence subgroups and increased most for LMD (+67%). After training, ≥27% of cases initially labeled LR or DR were later recognized as nLMD.This study highlights the large degree of inconsistency among clinicians in recognizing nLMD. Our findings demonstrate that a brief self-guided training module distinguishing nLMD can significantly improve IRR across all patterns of recurrence, and particularly in nLMD. To optimize outcomes reporting, prospective trials in brain metastases should incorporate central imaging review and investigator training.

    View details for DOI 10.1016/j.ijrobp.2019.10.002

    View details for PubMedID 31605786

  • Macrophage Exclusion after Radiation Therapy (MERT): A First in Human Phase I/II Trial using a CXCR4 Inhibitor in Glioblastoma. Clinical cancer research : an official journal of the American Association for Cancer Research Thomas, R. P., Nagpal, S. n., Iv, M. n., Soltys, S. G., Bertrand, S. n., Pelpola, J. S., Ball, R. L., Yang, J. n., Sundaram, V. n., Lavezo, J. L., Born, D. E., Vogel, H. n., Brown, J. M., Recht, L. n. 2019


    Preclinical studies have demonstrated that post-irradiation tumor revascularization is dependent on a stromal cell-derived factor-1 (SDF-1)/C-X-C chemokine receptor type 4 (CXCR4)-driven process in which myeloid cells are recruited from bone marrow. Blocking this axis results in survival improvement in preclinical models of solid tumors, including glioblastoma (GBM). We conducted a phase I/II study to determine the safety and efficacy of Macrophage Exclusion after Radiation Therapy (MERT) using the reversible CXCR4 inhibitor plerixafor in newly diagnosed glioblastoma patients.We enrolled 9 patients to the phase I study and an additional 20 patients to phase II using a modified toxicity probability interval (mTPI) design. Plerixafor was continuously infused intravenously via PICC line for four consecutive weeks beginning at day 35 of conventional treatment with concurrent chemo-radiation. Blood serum samples were obtained for pharmacokinetic analysis. Additional studies included relative cerebral blood volume (rCBV) analysis using MRI and histopathology analysis of recurrent tumors.Plerixafor was well tolerated with no drug-attributable grade 3 toxicities observed. At the maximum dose of 400 µg/kg/day, biomarker analysis found suprathreshold plerixafor serum levels and an increase in plasma SDF-1 levels. Median overall survival was 21.3 months (95% Confidence Interval (CI) 15.9, NA) with a progression-free survival of 14.5 months (95% CI 11.8, NA). MRI and histopathology support the mechanism of action to inhibit post-irradiation tumor revascularization.Infusion of the CXCR4 inhibitor plerixafor was well tolerated as an adjunct to standard chemo-irradiation in newly diagnosed GBM patients and improves local control of tumor recurrences.

    View details for DOI 10.1158/1078-0432.CCR-19-1421

    View details for PubMedID 31537527

  • Case closed: another prophylactic cranial irradiation trial for stage 3 non-small cell lung cancer fails to improve overall survival ANNALS OF TRANSLATIONAL MEDICINE Moghavem, N., Wakelee, H. A., Nagpal, S. 2018; 6
  • Central Nervous System Lymphoma in a Patient with Chronic Lymphocytic Leukemia: A Case Report and Literature Review. Cureus Albakr, A., Alhothali, W., Samghabadi, P., Maeda, L., Nagpal, S., Ajlan, A. 2018; 10 (11): e3660


    Chronic lymphocytic leukemia (CLL) is the most common type of leukemia that affects older adults in the Western world. Symptomatic nervous system invasion in undiagnosed CLL is rare, poorly understood, challenging to treat, and associated with decreased survival. The average survival of CLL patients with central nervous system (CNS) involvement is 3.79 years as compared to six years in CLL patients without CNS involvement. Autopsy studies demonstrated ahigh incidence of undiagnosed CLL with CNS involvement, suggesting that CNS involvement is either underdiagnosed or subclinical. Although the most common site of CNS involvement is the leptomeninges, our case demonstrates an extremely rare form of CNS diffuse large B-cell parenchymal involvement in a patient with a concurrent diagnosis of systemic CLL.

    View details for PubMedID 30755837

  • Developing a standardized process for oral chemotherapy management for neuro-oncology. McGranahan, T., Gershon, M., Pena, J., Bains, C., Van Meter, M., Salas, S., Nagpal, S. AMER SOC CLINICAL ONCOLOGY. 2018
  • A Diffuse Leptomeningeal Glioneuronal Tumor Without Diffuse Leptomeningeal Involvement: Detailed Molecular and Clinical Characterization JOURNAL OF NEUROPATHOLOGY AND EXPERIMENTAL NEUROLOGY Kung, J. H., Buckley, A. F., Nagpal, S., Fischbein, N., Peters, K. B. 2018; 77 (9): 751–56


    Prior to their provisional WHO classification as a distinct entity in 2016, diffuse leptomeningeal glioneuronal tumors (DLGNT) were often regarded as diffuse leptomeningeal presentations of oligodendrogliomas or extraventricular neurocytomas. Their classification as a distinct entity partly relies on their pattern of growth, but DLGNTs without radiological leptomeningeal involvement have been described. In a patient with a DLGNT of the spinal cord without evidence of leptomeningeal involvement, we review in depth the clinical course and the histologic and molecular features of the neoplasm, in the context of other reported cases without diffuse leptomeningeal involvement. Our findings highlight the advantages of molecular analysis in making accurate diagnoses on small spinal tissue samples and underline the need for more long-term clinical follow-up of these rare neoplasms to inform treatment decisions.

    View details for PubMedID 29931222

  • BPM 31510, a clinical stage metabolic modulator, demonstrates therapeutic efficacy in glioblastoma models of temozolomide chemosensitive and resistance by targeting mitochondrial function Dadali, T., Kulkarni, S., Ng, R., Awate, P., Mogre, S., Diers, A. R., Jang, T., Merchant, M., Sun, J., Gesta, S., Thapa, K., Nagpal, S., Recht, L., Narain, N. R., Sarangarajan, R. AMER ASSOC CANCER RESEARCH. 2018
  • Recurrently Mutated Genes Differ between Leptomeningeal and Solid Lung Cancer Brain Metastases. Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer Li, Y., Liu, B., Connolly, I. D., Kakusa, B. W., Pan, W., Nagpal, S., Montgomery, S. B., Hayden Gephart, M. 2018


    When compared with solid brain metastases from NSCLC, leptomeningeal disease (LMD) has unique growth patterns and is rapidly fatal. Patients with LMD do not undergo surgical resection, limiting the tissue available for scientific research. In this study we performed whole exome sequencing on eight samples of LMD to identify somatic mutations and compared the results with those for 26 solid brain metastases. We found that taste 2 receptor member 31 gene (TAS2R31) and phosphodiesterase 4D interacting protein gene (PDE4DIP) were recurrently mutated among LMD samples, suggesting involvement in LMD progression. Together with a retrospective review of the charts of an additional 44 patients with NSCLC LMD, we discovered a surprisingly low number of KRAS mutations (n= 4 [7.7%]) but a high number of EGFR mutations (n= 33 [63.5%]). The median interval for development of LMD from NSCLC was shorter in patients with mutant EGFR (16.3 months) than in patients with wild-type EGFR (23.9 months) (p= 0.017). Targeted analysis of recurrent mutations thus presents a useful complement to the existing diagnostic tool kit, and correlations of EGFR in LMD and KRAS in solid metastases suggest that molecular distinctions or systemic treatment pressure underpin the differences in growth patterns within the brain.

    View details for PubMedID 29604399

  • First-in-human intraoperative near-infrared fluorescence imaging of glioblastoma using cetuximab-IRDye800. Journal of neuro-oncology Miller, S. E., Tummers, W. S., Teraphongphom, N. n., van den Berg, N. S., Hasan, A. n., Ertsey, R. D., Nagpal, S. n., Recht, L. D., Plowey, E. D., Vogel, H. n., Harsh, G. R., Grant, G. A., Li, G. H., Rosenthal, E. L. 2018


    Maximizing extent of surgical resection with the least morbidity remains critical for survival in glioblastoma patients, and we hypothesize that it can be improved by enhancements in intraoperative tumor detection. In a clinical study, we determined if therapeutic antibodies could be repurposed for intraoperative imaging during resection.Fluorescently labeled cetuximab-IRDye800 was systemically administered to three patients 2 days prior to surgery. Near-infrared fluorescence imaging of tumor and histologically negative peri-tumoral tissue was performed intraoperatively and ex vivo. Fluorescence was measured as mean fluorescence intensity (MFI), and tumor-to-background ratios (TBRs) were calculated by comparing MFIs of tumor and histologically uninvolved tissue.The mean TBR was significantly higher in tumor tissue of contrast-enhancing (CE) tumors on preoperative imaging (4.0 ± 0.5) compared to non-CE tumors (1.2 ± 0.3; p = 0.02). The TBR was higher at a 100 mg dose than at 50 mg (4.3 vs. 3.6). The smallest detectable tumor volume in a closed-field setting was 70 mg with 50 mg of dye and 10 mg with 100 mg. On sections of paraffin embedded tissues, fluorescence positively correlated with histological evidence of tumor. Sensitivity and specificity of tumor fluorescence for viable tumor detection was calculated and fluorescence was found to be highly sensitive (73.0% for 50 mg dose, 98.2% for 100 mg dose) and specific (66.3% for 50 mg dose, 69.8% for 100 mg dose) for viable tumor tissue in CE tumors while normal peri-tumoral tissue showed minimal fluorescence.This first-in-human study demonstrates the feasibility and safety of antibody based imaging for CE glioblastomas.

    View details for PubMedID 29623552

  • Osimertinib for EGFR-Mutant Lung Cancer with Brain Metastases: Results from a Single-Center Retrospective Study. The oncologist Xie, L. n., Nagpal, S. n., Wakelee, H. A., Li, G. n., Soltys, S. G., Neal, J. W. 2018


    Osimertinib is a third-generation tyrosine kinase inhibitor, initially approved for epidermal growth factor receptor (EGFR) mutant non-small cell lung cancer (NSCLC) with T790M acquired resistance, and now approved in the first-line setting. However, data supporting the use of osimertinib in untreated brain metastases are limited, although it has established central nervous system (CNS) activity. Our study compares the clinical outcomes of patients experiencing progressing brain metastases treated with cranial irradiation and osimertinib with those treated with osimertinib alone.Forty patients who were treated with osimertinib at the Stanford Cancer Center from November 2015 to December 2016 were identified by searching an electronic medical record database. Eleven patients had progressing brain metastases and did not receive radiation (group A), 9 patients had progressing brain metastases and received radiation when starting osimertinib (group B), and 20 patients had stable brain metastases at the time of initiating osimertinib (group C). Patient and disease characteristics, radiographic responses, and survival outcomes were evaluated retrospectively for the three groups.The CNS response rate was 32.3%. Median time to treatment failure (TTF), overall progression-free survival (PFS), and overall survival (OS) were 10.0 months (95% confidence interval [CI], 4.5-11.8), 8.8 months (95% CI, 6.2-12.1), and 16.2 months, respectively. Median TTF was 15.1 months for group A (95% CI, 1.7-28.5), 7.7 months for group B (95% CI, 0-15.5), and 10.7 months for group C (95% CI, 9.0-12.5). The median PFS was 8.8 months for group A (95% CI, 4.3-13.4), not reached for group B, and 8.4 months for group C (95% CI, 5.6-11.1). The median OS was not reached for group A and C, and was 16.2 months for group B. There was no apparent difference in TTF, PFS, or OS between the three groups.Receiving radiation prior to starting osimertinib for patients with progressing brain metastases did not prolong TTF, PFS, or OS in our series. To minimize the risks of radiation-related toxicity, delaying radiation could be considered for some patients with EGFR-mutant NSCLC with brain metastases who initially respond to osimertinib in the second-line setting.Osimertinib is a third-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor recently approved for the first-line treatment of EGFR-mutant non-small cell lung cancer. Although it appears to have central nervous system (CNS) activity, most clinical trials have excluded patients with untreated, progressing brain metastases. This study included patients with stable and progressing CNS metastases treated with osimertinib and found no apparent differences in median time to treatment failure, time to progression, and overall survival in patients who received osimertinib alone compared with those who received osimertinib and radiosurgery. This may support a clinician's decision to defer radiation for selected patients with untreated brain metastases who are candidates for osimertinib therapy.

    View details for PubMedID 30126856

  • Conditional Probability of Survival as a Proposed Endpoint for Future Single-Arm Clinical Trials in Glioblastoma Patel, C. B., Thomas, R. P., Nagpal, S., Recht, L. D. WILEY. 2017: S206–S207
  • Optimizing bevacizumab dosing in glioblastoma: less is more. Journal of neuro-oncology Ajlan, A., Thomas, P., Albakr, A., Nagpal, S., Recht, L. 2017; 135 (1): 99-105


    Compared to traditional chemotherapies, where dose limiting toxicities represent the maximum possible dose, monoclonal antibody therapies are used at doses well below maximum tolerated dose. However, there has been little effort to ascertain whether there is a submaximal dose at which the efficacy/complication ratio is maximized. Thus, despite the general practice of using Bevacizumab (BEV) at dosages of 10 mg/kg every other week for glioma patients, there has not been much prior work examining whether the relatively high complication rates reported with this agent can be decreased by lowering the dose without impairing efficacy. We assessed charts from 80 patients who received BEV for glioblastoma to survey the incidence of complications relative to BEV dose. All patients were treated with standard upfront chemoradiation. The toxicity was graded based on the NCI CTCAE, version 4.03. The rate of BEV serious related adverse events was 12.5% (n = 10/80). There were no serious adverse events (≥grade 3) when the administered dose was (<3 mg/kg/week), compared to a 21% incidence in those who received higher doses (≥3 mg/kg/week) (P < 0.01). Importantly, the three patient deaths attributable to BEV administration occurred in patients receiving higher doses. Patients who received lower doses also had a better survival rate, although this did not reach statistical significance [median OS 39 for low dose group vs. 17.3 for high dose group (P = 0.07)]. Lower rates of serious BEV related toxicities are noted when lower dosages are used without diminishing positive clinical impact. Further work aimed at optimizing BEV dosage is justified.

    View details for DOI 10.1007/s11060-017-2553-2

    View details for PubMedID 28667595

  • History and current state of immunotherapy in glioma and brain metastasis THERAPEUTIC ADVANCES IN MEDICAL ONCOLOGY McGranahan, T., Li, G., Nagpal, S. 2017; 9 (5): 347-368


    Malignant brain tumors such as glioblastoma (GBM) and brain metastasis have poor prognosis despite conventional therapies. Successful use of vaccines and checkpoint inhibitors in systemic malignancy has increased the hope that immune therapies could improve survival in patients with brain tumors. Manipulating the immune system to fight malignancy has a long history of both modest breakthroughs and pitfalls that should be considered when applying the current immunotherapy approaches to patients with brain tumors. Therapeutic vaccine trials for GBM date back to the mid 1900s and have taken many forms; from irradiated tumor lysate to cell transfer therapies and peptide vaccines. These therapies were generally well tolerated without significant autoimmune toxicity, however also did not demonstrate significant clinical benefit. In contrast, the newer checkpoint inhibitors have demonstrated durable benefit in some metastatic malignancies, accompanied by significant autoimmune toxicity. While this toxicity was not unexpected, it exceeded what was predicted from pre-clinical studies and in many ways was similar to the prior trials of immunostimulants. This review will discuss the history of these studies and demonstrate that the future use of immune therapy for brain tumors will likely need a personalized approach that balances autoimmune toxicity with the opportunity for significant survival benefit.

    View details for DOI 10.1177/1758834017693750

    View details for Web of Science ID 000400896200004

    View details for PubMedID 28529551

    View details for PubMedCentralID PMC5424864

  • Phase 1/2 Trial of 5-Fraction Stereotactic Radiosurgery With 5-mm Margins With Concurrent and Adjuvant Temozolomide in Newly Diagnosed Supratentorial Glioblastoma: Health-Related Quality of Life Results. International journal of radiation oncology, biology, physics Pollom, E. L., Fujimoto, D., Wynne, J., Seiger, K., Modlin, L. A., Jacobs, L. R., Azoulay, M., von Eyben, R., Tupper, L., Gibbs, I. C., Hancock, S. L., Li, G., Chang, S. D., Adler, J. R., Harsh, G. R., Harraher, C., Nagpal, S., Thomas, R. P., Recht, L. D., Choi, C. Y., Soltys, S. G. 2017; 98 (1): 123-130


    We report a longitudinal assessment of health-related quality of life (HRQOL) in patients with glioblastoma (GBM) treated on a prospective dose escalation trial of 5-fraction stereotactic radiosurgery (25-40 Gy in 5 fractions) with concurrent and adjuvant temozolomide.HRQOL was assessed using the European Organization for Research and Treatment of Cancer (EORTC) quality of life questionnaire core-30 (QLQ-C30) general, the EORTC quality of life questionnaire-brain cancer specific module (QLQ-BN20), and the M.D. Anderson Symptom Inventory-Brain Tumor (MDASI-BT). Questionnaires were completed at baseline and at every follow-up visit after completion of radiosurgery. Changes from baseline for 9 predefined HRQOL measures (global quality of life, physical functioning, social functioning, emotional functioning, motor dysfunction, communication deficit, fatigue, insomnia, and future uncertainty) were calculated at every time point.With a median follow-up time of 10.4 months (range, 0.4-52 months), 139 total HRQOL questionnaires were completed by the 30 patients on trial. Compliance with HRQOL assessment was 76% at 12 months. Communication deficit significantly worsened over time, with a decline of 1.7 points per month (P=.008). No significant changes over time were detected in the other 8 scales of our primary analysis, including global quality of life. Although 8 patients (27%) experienced adverse radiation effects (ARE) on this dose escalation trial, it was not associated with a statistically significant decline in any of the primary HRQOL scales. Disease progression was associated with communication deficit, with patients experiencing an average worsening of 13.9 points per month after progression compared with 0.7 points per month before progression (P=.01).On this 5-fraction dose escalation protocol for newly diagnosed GBM, overall HRQOL remained stable and appears similar to historical controls of 30 fractions of radiation therapy. Tumor recurrence was associated with worsening communication deficit, and ARE did not correlate with a decline in HRQOL.

    View details for DOI 10.1016/j.ijrobp.2017.01.242

    View details for PubMedID 28586949

  • A Neuro-oncologist's Perspective on Management of Brain Metastases in Patients with EGFR Mutant Non-small Cell Lung Cancer. Current treatment options in oncology McGranahan, T., Nagpal, S. 2017; 18 (4): 22-?


    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.

    View details for DOI 10.1007/s11864-017-0466-0

    View details for PubMedID 28391420

  • Characterization of the peripheral neuropathy associated with brentuximab vedotin treatment of Mycosis Fungoides and Sézary Syndrome. Journal of neuro-oncology Corbin, Z. A., Nguyen-Lin, A., Li, S., Rahbar, Z., Tavallaee, M., Vogel, H., Salva, K. A., Wood, G. S., Kim, Y. H., Nagpal, S. 2017


    Chemotherapy-induced peripheral neuropathy (CIPN) is common, frequently limits chemotherapy dosing, and negatively impacts quality of life. The National Cancer Institute Common Toxicity Criteria for Adverse Events (CTCAE), version 4.0, and the Total Neuropathy Score clinical version (TNSc) are both validated scores to quantify peripheral neuropathy (PN), with the TNSc being more sensitive to clinical changes. Mycosis fungoides and Sézary syndrome (MF/SS) are characterized by a chronic course, where current therapies are generally non-curative and treatment toxicities have the potential for significant lasting effects. Brentuximab vedotin (BV) is an antibody-drug-conjugate composed of an anti-CD30 monoclonal antibody linked to the microtubule-disrupting agent, monomethyl auristatin E, with a known associated CIPN. In our phase II clinical trial of BV in MF/SS, 25 (69%) of 36 patients developed PN, with 18 (50%) developing Clinically Significant PN, CTCAE v4.0 grade 2 or higher. The median time to grade 2 PN was 15 weeks (range 0.4-48) after the initial dose. By Kaplan-Meier calculation, the median time to improvement from Clinically Significant PN was 30 weeks from the last BV dose. Seventy-four percent had improvement by 24 months. We found that TNSc scores significantly correlated with CTCAE grade, with Spearman correlation coefficient 0.68 (p < 0.001). By logistic regression, for each 100 mg increase in BV total dose, the likelihood of developing Clinically Significant PN increased by 23% (95% CI 4-46%). Improved monitoring of CIPN associated with BV is of paramount importance in the MF/SS population.

    View details for DOI 10.1007/s11060-017-2389-9

    View details for PubMedID 28271282

  • Stereotactic Radiosurgery and Hypofractionated Radiotherapy for Glioblastoma. Neurosurgery Shah, J. L., Li, G. n., Shaffer, J. L., Azoulay, M. I., Gibbs, I. C., Nagpal, S. n., Soltys, S. G. 2017


    Glioblastoma is the most common primary brain tumor in adults. Standard therapy depends on patient age and performance status but principally involves surgical resection followed by a 6-wk course of radiation therapy given concurrently with temozolomide chemotherapy. Despite such treatment, prognosis remains poor, with a median survival of 16 mo. Challenges in achieving local control, maintaining quality of life, and limiting toxicity plague treatment strategies for this disease. Radiotherapy dose intensification through hypofractionation and stereotactic radiosurgery is a promising strategy that has been explored to meet these challenges. We review the use of hypofractionated radiotherapy and stereotactic radiosurgery for patients with newly diagnosed and recurrent glioblastoma.

    View details for PubMedID 28605463

  • PS01.04: A Phase II Study of Etirinotecan Pegol (NKTR-102) in Patients with Refractory Brain Metastases and Advanced Lung Cancer: Topic: Medical Oncology. Journal of thoracic oncology Neal, J. W., Wakelee, H., Padda, S. K., Bertrand, S., Acevedo, B., Holmes Tisch, A., Pagtama, J. Y., Soltys, S. G., Nagpal, S. 2016; 11 (11S): S271-S272

    View details for DOI 10.1016/j.jtho.2016.09.040

    View details for PubMedID 27969472

  • A Phase I/II Trial of 5 Fraction Stereotactic Radiosurgery With 5-mm Margins With Concurrent and Adjuvant Temozolomide in Newly Diagnosed Supratentorial Glioblastoma Multiforme. International journal of radiation oncology, biology, physics Azoulay, M., Ho, C. K., Fujimoto, D. K., Modlin, L. A., Gibbs, I. C., Hancock, S. L., Li, G., Chang, S. D., Adler, J. R., Harsh, G. R., Nagpal, S., Thomas, R., Recht, L., Choi, C. Y., Soltys, S. G. 2016; 96 (2S): E131-E132

    View details for DOI 10.1016/j.ijrobp.2016.06.921

    View details for PubMedID 27673859

  • Tumor DNA in cerebral spinal fluid reflects clinical course in a patient with melanoma leptomeningeal brain metastases JOURNAL OF NEURO-ONCOLOGY Li, Y., Pan, W., Connolly, I. D., Reddy, S., Nagpal, S., Quake, S., Gephart, M. H. 2016; 128 (1): 93-100


    Cerebral spinal fluid (CSF) from brain tumor patients contains tumor cellular and cell-free DNA (cfDNA), which provides a less-invasive and routinely accessible method to obtain tumor genomic information. In this report, we used droplet digital PCR to test mutant tumor DNA in CSF of a patient to monitor the treatment response of metastatic melanoma leptomeningeal disease (LMD). The primary melanoma was known to have a BRAF (V600E) mutation, and the patient was treated with whole brain radiotherapy and BRAF inhibitors. We collected 9 CSF samples over 6 months. The mutant cfDNA fraction gradually decreased from 53 % (time of diagnosis) to 0 (time of symptom alleviation) over the first 6 time points. Three months after clinical improvement, the patient returned with severe symptoms and the mutant cfDNA was again detected in CSF at high levels. The mutant DNA fraction corresponded well with the patient's clinical response. We used whole exome sequencing to examine the mutation profiles of the LMD tumor DNA in CSF before therapeutic response and after disease relapse, and discovered a canonical cancer mutation PTEN (R130*) at both time points. The cellular and cfDNA revealed similar mutation profiles, suggesting cfDNA is representative of LMD cells. This study demonstrates the potential of using cellular or cfDNA in CSF to monitor treatment response for LMD.

    View details for DOI 10.1007/s11060-016-2081-5

    View details for PubMedID 26961773

  • The "Liquid Biopsy": the Role of Circulating DNA and RNA in Central Nervous System Tumors. Current neurology and neuroscience reports Connolly, I. D., Li, Y., Gephart, M. H., Nagpal, S. 2016; 16 (3): 25-?


    The detection of tumor-derived circulating nucleic acids in patients with cancer, known as the "liquid biopsy," has expanded from use in plasma to other bodily fluids in an increasing number of malignancies. Circulating nucleic acids could be of particular use in central nervous system tumors as biopsy carries a 5-7 % risk of major morbidity. This application presents unique challenges that have limited the use of cell-free DNA and RNA in the diagnosis and monitoring of CNS tumors. Recent work suggests that cerebrospinal fluid may be a useful source of CNS tumor-derived circulating nucleic acids. In this review, we discuss the available data and future outlook on the use of the liquid biopsy for CNS tumors.

    View details for DOI 10.1007/s11910-016-0629-6

    View details for PubMedID 26838352

  • Phase II Investigator-Initiated Study of Brentuximab Vedotin in Mycosis Fungoides and Sézary Syndrome With Variable CD30 Expression Level: A Multi-Institution Collaborative Project. Journal of clinical oncology Kim, Y. H., Tavallaee, M., Sundram, U., Salva, K. A., Wood, G. S., Li, S., Rozati, S., Nagpal, S., Krathen, M., Reddy, S., Hoppe, R. T., Nguyen-Lin, A., Weng, W., Armstrong, R., Pulitzer, M., Advani, R. H., Horwitz, S. M. 2015; 33 (32): 3750-3758


    In contrast to Hodgkin lymphoma and systemic anaplastic large-cell lymphoma, CD30 expression of malignant lymphocytes in mycosis fungoides (MF) and Sézary syndrome (SS) is quite variable. Clinical activity and safety of brentuximab vedotin, a CD30 targeting antibody-drug conjugate, was evaluated in MF and SS. Tissue and blood biomarkers of clinical response were explored.In this phase II study, patients with MF or SS with negligible to 100% CD30 expression levels were treated with brentuximab vedotin (1.8 mg/kg) every 3 weeks for a maximum of sixteen doses. The primary end point was overall global response rate. Secondary end points included correlation of tissue CD30 expression level with clinical response, time to response, duration of response, progression-free and event-free survivals, and safety.Of the 32 patients enrolled and treated, 30 patients had available efficacy evaluations. Objective global response was observed in 21 (70%) of 30 patients (90% CI, 53% to 83%). CD30 expression assessed by immunohistochemistry was highly variable, with a median CD30max of 13% (range, 0% to 100%). Those with <5% CD30 expression had a lower likelihood of global response than did those with 5% or greater CD30 expression (P < .005). CD163 positive tumor-associated macrophages, many of which coexpress CD30, were abundant in tissue. Peripheral neuropathy was the most common adverse event.Brentuximab vedotin demonstrated significant clinical activity in treatment-refractory or advanced MF or SS with a wide range of CD30 expression levels. Additional biomarker studies may help optimize rational design of combination therapies with brentuximab vedotin.

    View details for DOI 10.1200/JCO.2014.60.3969

    View details for PubMedID 26195720

  • Glioblastoma Multiforme Recurrence: An Exploratory Study of F-18 FPPRGD(2) PET/CT1 RADIOLOGY Iagaru, A., Mosci, C., Mittra, E., Zaharchuk, G., Fischbein, N., Harsh, G., Li, G., Nagpal, S., Recht, L., Gambhir, S. S. 2015; 277 (2): 497-506


    Purpose To prospectively evaluate fluorine 18 ((18)F) 2-fluoropropionyl-labeled PEGylated dimeric arginine-glycine-aspartic acid (RGD) peptide (PEG3-E[c{RGDyk}]2) (FPPRGD2) positron emission tomography (PET) in patients with glioblastoma multiforme (GBM). Materials and Methods The institutional review board approved this HIPAA-compliant protocol. Written informed consent was obtained from each patient. (18)F FPPRGD2 uptake was measured semiquantitatively in the form of maximum standardized uptake values (SUVmax) and uptake volumes before and after treatment with bevacizumab. Vital signs and laboratory results were collected before, during, and after the examinations. A nonparametric version of multivariate analysis of variance was used to assess safety outcome measures simultaneously across time points. A paired two-sample t test was performed to compare SUVmax. Results A total of 17 participants (eight men, nine women; age range, 25-65 years) were enrolled prospectively. (18)F FPPRGD2 PET/computed tomography (CT), (18)F fluorodeoxyglucose (FDG) PET/CT, and brain magnetic resonance (MR) imaging were performed within 3 weeks, prior to the start of bevacizumab therapy. In eight of the 17 patients (47%), (18)F FPPRGD2 PET/CT was repeated 1 week after the start of bevacizumab therapy; six patients (35%) underwent (18)F FPPRGD2 PET/CT a third time 6 weeks after starting bevacizumab therapy. There were no changes in vital signs, electrocardiographic findings, or laboratory values that qualified as adverse events. One patient (6%) had recurrent GBM identified only on (18)F FPPRGD2 PET images, and subsequent MR images enabled confirmation of recurrence. Of the 17 patients, 14 (82%) had recurrent GBM identified on (18)F FPPRGD2 PET and brain MR images, while (18)F FDG PET enabled identification of recurrence in 13 (76%) patients. Two patients (12%) had no recurrent GBM. Conclusion (18)F FPPRGD2 is a safe PET radiopharmaceutical that has increased uptake in GBM lesions. Larger cohorts are required to confirm these preliminary findings. (©) RSNA, 2015 Online supplemental material is available for this article.

    View details for DOI 10.1148/radiol.2015141550

    View details for Web of Science ID 000368435100026

  • Phase II pilot study of single-agent etirinotecan pegol (NKTR-102) in bevacizumab-resistant high grade glioma JOURNAL OF NEURO-ONCOLOGY Nagpal, S., Recht, C. K., Bertrand, S., Thomas, R. P., Ajlan, A., Pena, J., Gershon, M., Coffey, G., Kunz, P. L., Li, G., Recht, L. D. 2015; 123 (2): 277-282


    Patients with recurrence of high-grade glioma (HGG) after bevacizumab (BEV) have an extremely poor prognosis. Etirinotecan pegol (EP) is the first long-acting topoisomerase-I inhibitor designed to concentrate in and provide continuous tumor exposure throughout the entire chemotherapy cycle. Here we report results of a Phase 2, single arm, open-label trial evaluating EP in HGG patients who progressed after BEV. Patients age >18 with histologically proven anaplastic astrocytoma or glioblastoma (GB) who previously received standard chemo-radiation and recurred after BEV were eligible. A predicted life expectancy >6 weeks and KPS ≥ 50 were required. The primary endpoint was PFS at 6-weeks. Secondary endpoint was overall survival from first EP infusion. Response was assessed by RANO criteria. Single agent EP was administered IV every 3 weeks at 145 mg/m2. Patients did not receive BEV while on EP. 20 patients (90 % GB) were enrolled with a median age of 50 and median KPS of 70. Three patients with GB (16.7 % of GB) had partial MRI responses. 6-week PFS was 55 %. Median and 6-month PFS were 2.2 months (95 % CI 1.4-3.4 months) and 11.2 % (95 % CI 1.9-28.9 %) respectively. Median overall survival from first EP infusion was 4.5 months (95 % CI 2.4-5.9). Only one patient had grade 3 toxicity (diarrhea with dehydration) attributable to EP. Hematologic toxicity was mild. Three patients had confirmed partial responses according to RANO criteria. These clinical data combined with a favorable safety profile warrant further clinical investigation of this agent in HGG.

    View details for DOI 10.1007/s11060-015-1795-0

    View details for PubMedID 25935109

  • Cerebral Blood Flow Changes in Glioblastoma Patients Undergoing Bevacizumab Treatment Are Seen in Both Tumor and Normal Brain. The neuroradiology journal Andre, J. B., Nagpal, S., Hippe, D. S., Ravanpay, A. C., Schmiedeskamp, H., Bammer, R., Palagallo, G. J., Recht, L., Zaharchuk, G. 2015; 28 (2): 112-119


    Bevacizumab (BEV) is increasingly used to treat recurrent glioblastoma (GBM) with some reported improvement in neurocognitive function despite potential neurotoxicities. We examined the effects of BEV on cerebral blood flow (CBF) within recurrent GBM tumor and in the contralateral middle cerebral artery (MCA) territory.Post-chemoradiation patients with histologically confirmed GBM were treated with BEV and underwent routine, serial tumor imaging with additional pseudocontinuous arterial spin labeling (pcASL) following informed consent. Circular regions-of-interest were placed on pcASL images directly over the recurrent tumor and in the contralateral MCA territory. CBF changes before and during BEV treatment were evaluated in tumor and normal tissue. Linear mixed models were used to assess statistical significance.Fifty-three pcASL studies in 18 patients were acquired. Evaluation yielded lower mean tumoral CBF during BEV treatment compared with pre-treatment (45 ± 27 vs. 65 ± 27 ml/100 g/min, p = 0.002), and in the contralateral MCA territory during, compared with pre-BEV treatment (35 ± 8.4 vs. 41 ± 8.4 ml/100 g/min, p = 0.03). The decrease in mean CBF tended to be greater in the tumoral region than in the contralateral MCA, though the difference did not reach statistical significance (31% vs. 13%; p = 0.082).BEV administration results in statistically significant global CBF decrease with a potentially preferential decrease in tumor perfusion compared with normal brain tissue.

    View details for DOI 10.1177/1971400915576641

    View details for PubMedID 25923677

  • Brain Tumor Mutations Detected in Cerebral Spinal Fluid CLINICAL CHEMISTRY Pan, W., Gu, W., Nagpal, S., Gephart, M. H., Quake, S. R. 2015; 61 (3): 514-522


    Detecting tumor-derived cell-free DNA (cfDNA) in the blood of brain tumor patients is challenging, presumably owing to the blood-brain barrier. Cerebral spinal fluid (CSF) may serve as an alternative "liquid biopsy" of brain tumors by enabling measurement of circulating DNA within CSF to characterize tumor-specific mutations. Many aspects about the characteristics and detectability of tumor mutations in CSF remain undetermined.We used digital PCR and targeted amplicon sequencing to quantify tumor mutations in the cfDNA of CSF and plasma collected from 7 patients with solid brain tumors. Also, we applied cancer panel sequencing to globally characterize the somatic mutation profile from the CSF of 1 patient with suspected leptomeningeal disease.We detected tumor mutations in CSF samples from 6 of 7 patients with solid brain tumors. The concentration of the tumor mutant alleles varied widely between patients, from <5 to nearly 3000 copies/mL CSF. We identified 7 somatic mutations from the CSF of a patient with leptomeningeal disease by use of cancer panel sequencing, and the result was concordant with genetic testing on the primary tumor biopsy.Tumor mutations were detectable in cfDNA from the CSF of patients with different primary and metastatic brain tumors. We designed 2 strategies to characterize tumor mutations in CSF for potential clinical diagnosis: the targeted detection of known driver mutations to monitor brain metastasis and the global characterization of genomic aberrations to direct personalized cancer care.

    View details for DOI 10.1373/clinchem.2014.235457

    View details for Web of Science ID 000352161300013

    View details for PubMedID 25605683

  • Prolonged survival of patients with non-small-cell lung cancer with leptomeningeal carcinomatosis in the modern treatment era. Clinical lung cancer Riess, J. W., Nagpal, S., Iv, M., Zeineh, M., Gubens, M. A., Ramchandran, K., Neal, J. W., Wakelee, H. A. 2014; 15 (3): 202-206


    Leptomeningeal carcinomatosis (LM) is a severe complication of non-small-cell lung cancer (NSCLC) historically associated with poor prognosis. New chemotherapeutic and targeted treatments could potentially affect the natural history of LM.Patients with a pathologic diagnosis of NSCLC with LM treated at Stanford between 2003 and 2011 were identified via institutional databases and medical records. LM was defined by cerebrospinal fluid (CSF) that was positive for malignant cells or by LM enhancement on magnetic resonance imaging with gadolinium contrast. Retrospective, landmark analyses were performed to estimate survival. Statistical analyses were performed using SAS Enterprise Guide, version 4.3.LM was identified in 30 patients. All cases were adenocarcinoma; 60% of patients had a known or suspected driver mutation. The mean age was 58 years. Of the 30 patients, 67% were women; 70% were nonsmokers; 27% initially presented with LM; 84% received systemic treatment at or after development of LM; and 53% of these patients received modern systemic therapy for their LM, defined as a regimen containing pemetrexed, bevacizumab, or a tyrosine kinase inhibitor. Mean overall survival after LM diagnosis was 6 months (95% CI, 3-12). Patients who received modern systemic therapy for LM had decreased hazard of death (hazard ratio [HR], 0.24; P = .007).In this retrospective, single-institution analysis, median survival with LM was higher compared with historical experience. Patients who received modern systemic therapy for their LM had particularly good outcomes. These data provide evidence for improving survival outcomes in the modern treatment era for this difficult-to-treat complication.

    View details for DOI 10.1016/j.cllc.2013.12.009

    View details for PubMedID 24524822

  • Risk of Leptomeningeal Disease in Patients Treated With Stereotactic Radiosurgery Targeting the Postoperative Resection Cavity for Brain Metastases INTERNATIONAL JOURNAL OF RADIATION ONCOLOGY BIOLOGY PHYSICS Atalar, B., Modlin, L. A., Choi, C. Y., Adler, J. R., Gibbs, I. C., Chang, S. D., Harsh, G. R., Li, G., Nagpal, S., Hanlon, A., Soltys, S. G. 2013; 87 (4): 713-718


    We sought to determine the risk of leptomeningeal disease (LMD) in patients treated with stereotactic radiosurgery (SRS) targeting the postsurgical resection cavity of a brain metastasis, deferring whole-brain radiation therapy (WBRT) in all patients.We retrospectively reviewed 175 brain metastasis resection cavities in 165 patients treated from 1998 to 2011 with postoperative SRS. The cumulative incidence rates, with death as a competing risk, of LMD, local failure (LF), and distant brain parenchymal failure (DF) were estimated. Variables associated with LMD were evaluated, including LF, DF, posterior fossa location, resection type (en-bloc vs piecemeal or unknown), and histology (lung, colon, breast, melanoma, gynecologic, other).With a median follow-up of 12 months (range, 1-157 months), median overall survival was 17 months. Twenty-one of 165 patients (13%) developed LMD at a median of 5 months (range, 2-33 months) following SRS. The 1-year cumulative incidence rates, with death as a competing risk, were 10% (95% confidence interval [CI], 6%-15%) for developing LF, 54% (95% CI, 46%-61%) for DF, and 11% (95% CI, 7%-17%) for LMD. On univariate analysis, only breast cancer histology (hazard ratio, 2.96) was associated with an increased risk of LMD. The 1-year cumulative incidence of LMD was 24% (95% CI, 9%-41%) for breast cancer compared to 9% (95% CI, 5%-14%) for non-breast histology (P=.004).In patients treated with SRS targeting the postoperative cavity following resection, those with breast cancer histology were at higher risk of LMD. It is unknown whether the inclusion of whole-brain irradiation or novel strategies such as preresection SRS would improve this risk or if the rate of LMD is inherently higher with breast histology.

    View details for DOI 10.1016/j.ijrobp.2013.07.034

    View details for Web of Science ID 000325763300022

    View details for PubMedID 24054875

  • Simultaneous perfusion and permeability measurements using combined spin- and gradient-echo MRI. Journal of cerebral blood flow and metabolism Schmiedeskamp, H., Andre, J. B., Straka, M., Christen, T., Nagpal, S., Recht, L., Thomas, R. P., Zaharchuk, G., Bammer, R. 2013; 33 (5): 732-743


    The purpose of this study was to estimate magnetic resonance imaging-based brain perfusion parameters from combined multiecho spin-echo and gradient-echo acquisitions, to correct them for T1-, T2-, and -related contrast agent (CA) extravasation effects, and to simultaneously determine vascular permeability. Perfusion data were acquired using a combined multiecho spin- and gradient-echo (SAGE) echo-planar imaging sequence, which was corrected for CA extravasation effects using pharmacokinetic modeling. The presented method was validated in simulations and brain tumor patients, and compared with uncorrected single-echo and multiecho data. In the presence of CA extravasation, uncorrected single-echo data resulted in underestimated CA concentrations, leading to underestimated single-echo cerebral blood volume (CBV) and mean transit time (MTT). In contrast, uncorrected multiecho data resulted in overestimations of CA concentrations, CBV, and MTT. The correction of CA extravasation effects resulted in CBV and MTT estimates that were more consistent with the underlying tissue characteristics. Spin-echo perfusion data showed reduced large-vessel blooming effects, facilitating better distinction between increased CBV due to active tumor progression and elevated CBV due to the presence of cortical vessels in tumor proximity. Furthermore, extracted permeability parameters were in good agreement with elevated T1-weighted postcontrast signal values.

    View details for DOI 10.1038/jcbfm.2013.10

    View details for PubMedID 23462570

  • A Patient With Anaplastic Lymphoma Kinase-Positive Non-Small Cell Lung Cancer With Development of Leptomeningeal Carcinomatosis While on Targeted Treatment With Crizotinib JOURNAL OF THE NATIONAL COMPREHENSIVE CANCER NETWORK Riess, J. W., Nagpal, S., Neal, J. W., Wake, H. A. 2013; 11 (4): 389-394


    Leptomeningeal carcinomatosis (LM) is an infrequent yet morbid and often fatal complication of non-small cell lung cancer (NSCLC). Management of LM is multimodal, often involving systemic chemotherapy, radiotherapy, and a variety of symptom management maneuvers to address elevated intracranial pressure, pain, and mood changes that can accompany the disease. It is increasingly recognized that tumors with actionable mutations in NSCLC, including epidermal growth factor receptor (EGFR) mutations and anaplastic lymphoma kinase (ALK) translocations, respond well to systemic therapy with tyrosine kinase inhibitors yet often progress in the central nervous system. More information is needed regarding the natural history and optimal management of LM in specific molecular subtypes of NSCLC. This case report summarizes the management of a patient with ALK-positive NSCLC who developed LM while on targeted treatment with crizotinib within the context of current NCCN Clinical Practice Guidelines in Oncology and recently published studies.

    View details for PubMedID 23584342

  • ETIRINOTECAN PEGOL DNA Topoisomerase 1 Inhibitor Oncolytic DRUGS OF THE FUTURE Nagpal, S., Recht, L. D. 2013; 38 (4): 227-233
  • The incidence and significance of multiple lesions in glioblastoma JOURNAL OF NEURO-ONCOLOGY Thomas, R. P., Xu, L. W., Lober, R. M., Li, G., Nagpal, S. 2013; 112 (1): 91-97


    The location and distribution of glioblastoma (GBM) within the brain parenchyma plays an important role in surgical and radiation planning. Prior studies have reported incidences of multiple lesions at the time of diagnosis ranging from 0.5 to 20 %. Multiple lesions can be further categorized as multifocal (multiple areas involved, but with a clear path of spread from one lesion to another) or multicentric (multiple lesions, no clear path of spread). In this retrospective study, we reviewed our experience with GBM and found the incidence of multiple lesions at time of diagnosis was 35 %, much higher than previously suggested in the literature. Patients with single lesions had an improved overall survival when compared to patients with multiple lesions (18 vs. 10 months). Patients with multicentric lesions fared the worst, with average survival of 3 months. However, the difference between single and multiple lesions (multifocal or multicentric) was no longer significant when taking into consideration age, Karnofsky performance score (KPS) and extent of resection by multivariate analysis. Age, KPS, gross total resection, and MGMT status were independent predictors of outcome. Multiple lesions did not independently confer a worse outcome, but were associated with lower KPS scores and inability to perform gross total resection. These findings suggest that single, multiple and multicentric imaging exams represent a spectrum of presentations of a single disease. The rate of multiple lesions reported here may be the result of improved imaging technology, suggesting that incidence of multiple lesions will continue to increase as imaging technology advances.

    View details for DOI 10.1007/s11060-012-1030-1

    View details for PubMedID 23354652

  • A case series of NSCLC patients with different molecular characteristics and choroidal metastases: improvement in vision with treatment including pemetrexed and bevacizumab. Journal of thoracic oncology Riess, J. W., Nagpal, S., Das, M., Neal, J. W., Kim, J. W., Wakelee, H. A. 2013; 8 (2): e17-8

    View details for DOI 10.1097/JTO.0b013e31827690da

    View details for PubMedID 23328555

    View details for PubMedCentralID PMC3552378

  • EGFR mutation status and brain metastases in non-small cell lung cancer: an understudied problem TRANSLATIONAL CANCER RESEARCH Riess, J. W., Nagpal, S. 2013; 2 (1): 54-56
  • A Case Series of NSCLC Patients with Different Molecular Characteristics and Choroidal Metastases Improvement in Vision with Treatment Including Pemetrexed and Bevacizumab JOURNAL OF THORACIC ONCOLOGY Riess, J. W., Nagpal, S., Das, M., Neal, J. W., Kim, J. W., Wakelee, H. A. 2013; 8 (2): E17-E18

    View details for DOI 10.1097/JTO.0b013e31827690da

    View details for Web of Science ID 000316204900003

    View details for PubMedID 23328555

    View details for PubMedCentralID PMC3552378

  • Advances in the management of glioblastoma: the role of temozolomide and MGMT testing. Clinical pharmacology : advances and applications Thomas, R. P., Recht, L., Nagpal, S. 2013; 5: 1-9


    Glioblastoma (GB) is one of the most lethal forms of cancer, with an invasive growth pattern that requires the use of adjuvant therapies, including chemotherapy and radiation, to prolong survival. Temozolomide (TMZ) is an oral chemotherapy with a limited side effect profile that has become the standard of care in GB treatment. While TMZ has made an impact on survival, tumor recurrence and TMZ resistance remain major challenges. Molecular markers, such as O6-methylguanine-DNA methyltransferase methylation status, can be helpful in predicting tumor response to TMZ, and therefore guides clinical decision making. This review will discuss the epidemiology and possible genetic underpinnings of GB, how TMZ became the standard of care for GB patients, the pharmacology of TMZ, the practical aspects of using TMZ in clinic, and how molecular diagnostics - particularly the use of O6-methylguanine-DNA methyltransferase status - affect clinical management.

    View details for DOI 10.2147/CPAA.S26586

    View details for PubMedID 23293540

  • Treatment of Leptomeningeal Spread of NSCLC: A Continuing Challenge CURRENT TREATMENT OPTIONS IN ONCOLOGY Nagpal, S., Riess, J., Wakelee, H. 2012; 13 (4): 491-504


    OPINION STATEMENT: Leptomeningeal metastasis is a serious and frequently fatal complication of non-small cell lung cancer. Curative treatment remains elusive, but careful use of radiation, systemic chemotherapy, intrathecal chemotherapy, and symptoms management can greatly improve quality of life and survival. For most patients, we recommend a combination of skull-based radiation with focal radiation to any symptomatic spinal segments followed by systemic chemotherapy. For patients with EGFR mutations, erlotinib may be used as first-line therapy in a daily or high-dose regimen. Pemetrexed has promise for use in patients with brain and leptomeningeal metastases. Patients with multiple comorbidities or low performance status may tolerate intrathecal therapy better than systemic chemotherapy. The most commonly used intrathecal chemotherapies are methotrexate and liposomal cytarabine, although newer agents, such as topotecan and mafosfamide, may be more effective. Elevated intracranial pressure, which causes headaches, vertigo, nausea, and vomiting, should be treated with dexamethasone and acetazolamide. In select patients, cerebrospinal fluid shunting may be considered. The use of antidepressants, central nervous system stimulants, benzodiazepines, antiemetics, and pain medications can increase quality of life in patients with leptomeningeal metastases.

    View details for DOI 10.1007/s11864-012-0206-4

    View details for Web of Science ID 000311292500006

    View details for PubMedID 22836285

  • Polymer Wafers (Gliadel) in the Treatment of Malignant Glioma NEUROSURGERY CLINICS OF NORTH AMERICA Nagpal, S. 2012; 23 (2): 289-?


    The 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU; carmustine) polymer wafer (Gliadel) was developed for use in malignant glioma to deliver higher doses of chemotherapy directly to tumor tissue while bypassing systemic side effects. Phase III clinical trials for patients with newly diagnosed malignant gliomas demonstrated a small, but statistically significant, improvement in survival. However, the rate of complications, including an increase in cerebrospinal fluid leaks and intracranial hypertension, has limited their use. This article reviews the current data for use of BCNU wafers in malignant gliomas.

    View details for DOI 10.1016/

    View details for Web of Science ID 000303282100011

    View details for PubMedID 22440872

  • Neoplastic Myelopathy SEMINARS IN NEUROLOGY Nagpal, S., Clarke, J. L. 2012; 32 (2): 137-145


    Neoplastic myelopathy may be due to external compression or to direct intraparenchymal involvement of the spinal cord. In this review, the authors discuss the most common cause for compressive neoplastic myelopathy, metastatic disease. They also review other compressive lesions and discuss primary intramedullary spinal tumors. In the acute setting, compressive metastatic disease should be treated with high-dose steroids when clinically necessary; surgery should be considered for selected patients, followed by radiation therapy. For most primary intramedullary spinal tumors, surgical resection remains the standard initial therapy. Patients with incomplete resection of infiltrative tumors, high-grade pathology, or recurrent tumors may benefit from radiation, but most spinal tumors are relatively insensitive to traditional chemotherapy. Neoplastic myelopathy from either compressive or intraparenchymal causes remains a diagnostic and therapeutic challenge. In complex cases, referral to a specialty center with access to neurosurgeons, neuroradiologists, neuropathologists, and neurooncologists is recommended.

    View details for DOI 10.1055/s-0032-1322584

    View details for Web of Science ID 000307423200005

    View details for PubMedID 22961188

  • Treatment and Prophylaxis of Hematologic Malignancy in the Central Nervous System CURRENT TREATMENT OPTIONS IN NEUROLOGY Nagpal, S., Recht, L. 2011; 13 (4): 400-412


    OPINION STATEMENT: Central nervous system (CNS) involvement is a serious, and frequently fatal, complication of acute leukemias and very aggressive lymphomas. In patients with no evidence of CNS involvement at the time of diagnosis, the decision to include CNS prophylaxis in the treatment regimen should be based on cytologic diagnosis and other risk factors. Patients with a risk of CNS relapse greater than 10% should receive CNS prophylaxis with high-dose systemic chemotherapy, intrathecal therapy, radiation, or a combination thereof. The most commonly used systemic and intrathecal chemotherapies are methotrexate and cytarabine. Liposomal cytarabine, which increases CNS bioavailability and decreases the number of lumbar punctures needed, is our preference for intrathecal therapy. We usually reserve radiation therapy for patients who may not tolerate other forms of CNS prophylaxis. Patients with evidence of CNS involvement, either at diagnosis or relapse, should be treated until CNS disease clearance or dose-limiting toxicity is reached. Recent studies suggest that autologous stem cell transplantation may offer longer survivals for patients with CNS involvement and should be considered for patients who can tolerate the procedure. The use of rituximab in CNS prophylaxis and treatment has not yet been clearly delineated, but initial reports indicate that this agent and others may soon be available as an effective and tolerable CNS-directed therapy for lymphomas.

    View details for DOI 10.1007/s11940-011-0128-7

    View details for Web of Science ID 000292402500007

    View details for PubMedID 21484261

  • Bevacizumab improves quality of life in patients with recurrent glioblastoma. Chemotherapy research and practice Nagpal, S., Harsh, G., Recht, L. 2011; 2011: 602812-?


    Objective. To quantify the benefits in survival and quality of life in patients receiving bevacizumab (BEV) for recurrent glioblastoma (GBM). Methods. This is a retrospective study of 40 adult patients with recurrent GBM treated between 2005 and 2009 at a single institution. All patients had initial treatment with surgery, radiation, and concurrent temozolomide, then monthly temozolomide. Over 250 charts were screened. Sufficient data was available for 20 patients treated with BEV and 20 patients who did not receive BEV at the time of recurrence. The independent living score (ILS), designed to reward long-term independent survival, was calculated for each patient. Results. The mean ILS was nearly double in the BEV group compared to the No-BEV group (15.0 versus 8.2, P = 0.002, t-test). Two months after initiation of therapy, the median steroid dose dropped by over 90% in patients treated with BEV, but doubled in the NoBEV group. Median survival from the time of recurrence was significantly affected: 10.6 months in the BEV group versus 4.2 months (P < 0.001, log rank survival) in the NoBEV group. Conclusions. BEV increases independent living and lengthens overall survival after GBM recurrence. Reduction in steroid dose may contribute to prolonged independence.

    View details for DOI 10.1155/2011/602812

    View details for PubMedID 22312554

    View details for PubMedCentralID PMC3263615

  • Cardiac Rupture After Intravenous t-PA Administration in Acute Ischemic Stroke NEUROCRITICAL CARE Dhand, A., Nakagawa, K., Nagpal, S., Gelfand, J. M., Kim, A. S., Smith, W. S., Tihan, T. 2010; 13 (2): 261-262


    Ventricular free wall rupture is a fatal complication of myocardial infarction (MI). Although described in MI patients who receive thrombolytic therapy, this complication is not well known in ischemic stroke patients who receive intravenous (IV) t-PA.Case report.We present a 93-year-old woman with an acute onset of a right middle cerebral artery syndrome in the setting of subacute MI. IV t-PA was administered and she subsequently developed asystolic arrest and died. Autopsy showed subacute MI, hemopericardium, and rupture of the left ventricle.This case illustrates a fatal cardiac complication of IV thrombolytic therapy for stroke. The speculated mechanism is hemorrhage into the infarcted myocardium.

    View details for DOI 10.1007/s12028-010-9384-8

    View details for Web of Science ID 000282093500018

    View details for PubMedID 20697837

  • Treatment and Prevention of Secondary CNS Lymphoma SEMINARS IN NEUROLOGY Nagpal, S., Glantz, M. J., Recht, L. 2010; 30 (3): 263-272


    Central nervous system (CNS) involvement in non-Hodgkin lymphoma is a serious, potentially preventable complication that can occur in 5 to 10% of patients. Its occurrence is directly correlated with pathologic aggressiveness and ranges from less than 3% in the indolent, less-aggressive histologies to as high as 50% in the very aggressive ones such as Burkitt lymphoma. Aggressive treatment once detected can improve neurologic outcome, but because it is often associated with contemporaneous systemic relapse, is rarely associated with long-term survival. Preventing its occurrence, therefore, remains an important goal of initial treatment. Despite there being some suggestive evidence that the addition of systemic rituximab and several intracerebrospinal fluid chemotherapy regimens may have decreased the incidence of CNS involvement, both optimal selection of those patients who should receive prophylaxis as well as the best prophylactic regimen remain active areas of investigation.

    View details for DOI 10.1055/s-0030-1255222

    View details for Web of Science ID 000279572600007

    View details for PubMedID 20577933

  • Decompressive laparotomy to treat intractable cerebral hypoxia. journal of trauma Nagpal, S., Halpern, C. H., Sims, C., Calland, J. F., Gracias, V. H., Schuster, J. M., LeRoux, P. D., Levine, J. M. 2009; 67 (5): E152-5

    View details for DOI 10.1097/TA.0b013e3180593657

    View details for PubMedID 19088554

  • Vasospasm as the sole cause of cerebral ischemia: how strong is the evidence? Neurosurgical focus Stein, S. C., Levine, J. M., Nagpal, S., LeRoux, P. D. 2006; 21 (3): E2-?


    The authors review literature that challenges the view that vasospasm involving large arteries is the exclusive cause of delayed ischemic neurological deficits (DINDs) following subarachnoid hemorrhage. They discuss alternative mechanisms and review the evidence supporting a potential role for thromboembolism. They conclude that vasospasm and thromboembolism play interrelated and additive roles in the development of DINDs, and that this interaction provides opportunities for novel therapeutic approaches.

    View details for PubMedID 17029341

  • Management of patients with Schwan nomatosis: Report of six cases and review of the literature SURGICAL NEUROLOGY Huang, J. H., Simon, S. L., Nagpal, S., Nelson, P. T., Zager, E. L. 2004; 62 (4): 353-361


    Schwannomatosis is a rare tumor syndrome characterized by the presence of multiple schwannomas without the stigmata of neurofibromatosis (NF) Type 1 or 2. To better understand the natural history and clinical management of the syndrome, a retrospective review was conducted of patients diagnosed with schwannomatosis over an 11-year period at the University of Pennsylvania Medical Center (UPMC).Between 1990 and 2001, 131 patients underwent surgery for resection of spinal or peripheral nerve schwannomas in the Department of Neurosurgery at the University of Pennsylvania Medical Center. Among the 131 patients, there were 6 who had two or more pathologically proven schwannomas without radiographic or clinical evidence of vestibular schwannomas. The hospital charts, clinic notes, radiology films, operative reports, pathology slides, and reports from all 6 patients were retrospectively reviewed.The patient population consisted of 6 patients with a mean age of 48.7 (3 male: 3 female). All patients had enhanced brain magnetic resonance imaging (MRI) scans that were negative for vestibular schwannomas. Ophthalmological and general physical examinations did not reveal any findings suggestive of NF. There was no family history of NF or schwannomatosis. The locations of the schwannomas included intraspinal (multiple sites), paraspinal, brachial plexus, femoral nerve, sciatic nerve, calf, forearm, retroperitoneum, and middle cranial/infratemporal fossa region. The common presenting symptoms included paresthesias, palpable mass, pain, or weakness. All 6 patients underwent surgical resection of symptomatic lesions.For patients with schwannomatosis, surgery is indicated for symptomatic lesions, while asymptomatic tumors are followed conservatively. Because these patients are at increased risk for developing multiple schwannomas, we recommend regular surveillance and offer genetic counseling even though the pattern of inheritance is unknown.

    View details for DOI 10.1016/j.surneu.2003.11.020

    View details for Web of Science ID 000224263300013

    View details for PubMedID 15451291