Skip to main content

Advertisement

SpringerLink
Log in

The breast graded prognostic assessment is associated with the survival outcomes in breast cancer patients receiving whole brain re-irradiation

  • Clinical Study
  • Published:
Journal of Neuro-Oncology Aims and scope Submit manuscript

Abstract

Introduction

Whole brain (WB) re-irradiation for breast cancer patients with progressive brain metastasis after first-course WB radiotherapy (WBRT) is controversial. In this study, we sought to investigate the association between the molecular sub-classifications and breast-specific Graded Prognostic Assessment (GPA, which includes the Karnofsky performance status, molecular subtypes, and age as its indices) and the outcomes of breast cancer patients who received WB re-irradiation.

Methods

Twenty-three breast cancer patients who received WB re-irradiation for relapsed and progressive intracranial lesions after first-course WBRT between 2004 and 2016 were retrospectively reviewed. Patients were divided according to the 4 molecular subtypes of luminal A/B (hormone receptor [HR]+/human epidermal growth factor receptor 2 [HER2]−), luminal HER2 (HR+/HER2+), HER2 (HR−/HER2+), and triple negative (HR−/HER2−). The clinical and radiological responses and survival rates after WB re-irradiation were analyzed.

Results

At 1 month after WB re-irradiation, 13 of 23 patients (56.5%) exhibited disappearance or alleviation of neurological symptoms. The median survival time after WB re-irradiation was 2.93 months (95% confidence interval [CI], 1.79–4.08). After WB re-irradiation, patients with HER2-negative tumors had poorer median survival times than those with HER2-positive tumors (2.23 vs. 3.0 months, respectively; p = 0.022). Furthermore, patients with high breast GPA scores (2.5–4.0, n = 11) had longer median survivals than those with low-scores (0–2.0, n = 12) after WB re-irradiation (4.37 vs. 1.57 months, respectively; p < 0.005).

Conclusions

WB re-irradiation may be a feasible treatment option for certain breast cancer patients who develop brain metastatic lesions after first-course WBRT when these lesions are ineligible for radiosurgery or surgery.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Lin NU, Bellon JR, Winer EP (2004) CNS metastases in breast cancer. J Clin Oncol 22(17):3608–3617. https://doi.org/10.1200/JCO.2004.01.175

    Article  PubMed  Google Scholar 

  2. Weil RJ, Palmieri DC, Bronder JL, Stark AM, Steeg PS (2005) Breast cancer metastasis to the central nervous system. Am J Pathol 167(4):913–920. https://doi.org/10.1016/S0002-9440(10)61180-7

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  3. Bendell JC, Domchek SM, Burstein HJ, Harris L, Younger J, Kuter I, Bunnell C, Rue M, Gelman R, Winer E (2003) Central nervous system metastases in women who receive trastuzumab-based therapy for metastatic breast carcinoma. Cancer 97(12):2972–2977. https://doi.org/10.1002/cncr.11436

    Article  PubMed  Google Scholar 

  4. Altaha R, Crowell E, Ducatman B, Higa G, Abraham J (2004) Risk of brain metastases in HER2/neu-positive breast cancer. J Clin Oncol 22(14_suppl):682–682. https://doi.org/10.1200/jco.2004.22.90140.682

    Article  Google Scholar 

  5. Stemmler H, Kahlert S, Siekiera W, Untch M, Heinrich B, Heinemann V (2006) Characteristics of patients with brain metastases receiving trastuzumab for HER2 overexpressing metastatic breast cancer. Breast 15(2):219–225. https://doi.org/10.1016/j.breast.2005.04.017

    Article  PubMed  CAS  Google Scholar 

  6. Berghoff A, Bago-Horvath Z, De Vries C, Dubsky P, Pluschnig U, Rudas M, Rottenfusser A, Knauer M, Eiter H, Fitzal F (2012) Brain metastases free survival differs between breast cancer subtypes. Br J Cancer 106(3):440–446. https://doi.org/10.1038/bjc.2011.597

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  7. Olson E, Abdel-Rasoul M, Maly J, Wu C, Lin N, Shapiro C (2013) Incidence and risk of central nervous system metastases as site of first recurrence in patients with HER2-positive breast cancer treated with adjuvant trastuzumab. Ann Oncol 24(6):1526–1533. https://doi.org/10.1093/annonc/mdt036

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  8. Aoyama H, Shirato H, Tago M, Nakagawa K, Toyoda T, Hatano K, Kenjyo M, Oya N, Hirota S, Shioura H (2006) Stereotactic radiosurgery plus whole-brain radiation therapy vs stereotactic radiosurgery alone for treatment of brain metastases: a randomized controlled trial. JAMA 295(21):2483–2491. https://doi.org/10.1001/jama.295.21.2483

    Article  PubMed  CAS  Google Scholar 

  9. Sahgal A, Aoyama H, Kocher M, Neupane B, Collette S, Tago M, Shaw P, Beyene J, Chang EL (2015) Phase 3 trials of stereotactic radiosurgery with or without whole-brain radiation therapy for 1 to 4 brain metastases: individual patient data meta-analysis. Int J Radiat Oncol Biol Phys 91(4):710–717. https://doi.org/10.1016/j.ijrobp.2014.10.024

    Article  PubMed  Google Scholar 

  10. Tsao M, Xu W, Sahgal A (2012) A meta-analysis evaluating stereotactic radiosurgery, whole-brain radiotherapy, or both for patients presenting with a limited number of brain metastases. Cancer 118(9):2486–2493. https://doi.org/10.1002/cncr.26515

    Article  PubMed  Google Scholar 

  11. McTyre E, Scott J, Chinnaiyan P (2013) Whole brain radiotherapy for brain metastasis. Surg Neurol Int 4(Suppl 4):S236

    PubMed  PubMed Central  Google Scholar 

  12. Owonikoko TK, Arbiser J, Zelnak A, Shu H-KG, Shim H, Robin AM, Kalkanis SN, Whitsett TG, Salhia B, Tran NL (2014) Current approaches to the treatment of metastatic brain tumours. Nat Rev Clin Oncol 11(4):203–222. https://doi.org/10.1038/nrclinonc.2014.25

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  13. O’Sullivan CC, Davarpanah NN, Abraham J, Bates SE (2017) Current challenges in the management of breast cancer brain metastases. Semin Oncol 44(2):85–100. https://doi.org/10.1053/j.seminoncol.2017.06.006

    Article  PubMed  CAS  Google Scholar 

  14. Fokstuen T, Wilking N, Rutqvist LE, Wolke J, Liedberg A, Signomklao T, Fernberg J-O (2000) Radiation therapy in the management of brain metastases from breast cancer. Breast Cancer Res Treat 62(3):211–216. https://doi.org/10.1023/A:1006486423827

    Article  PubMed  CAS  Google Scholar 

  15. Khuntia D, Brown P, Li J, Mehta MP (2006) Whole-brain radiotherapy in the management of brain metastasis. J Clin Oncol 24(8):1295–1304. https://doi.org/10.1200/JCO.2005.04.6185

    Article  PubMed  CAS  Google Scholar 

  16. Lentzsch S, Reichardt P, Weber F, Budach V, Dörken B (1999) Brain metastases in breast cancer: prognostic factors and management. Eur J Cancer 35(4):580–585. https://doi.org/10.1016/S0959-8049(98)00421-3

    Article  PubMed  CAS  Google Scholar 

  17. Gabos Z, Sinha R, Hanson J, Chauhan N, Hugh J, Mackey JR, Abdulkarim B (2006) Prognostic significance of human epidermal growth factor receptor positivity for the development of brain metastasis after newly diagnosed breast cancer. J Clin Oncol 24(36):5658–5663. https://doi.org/10.1200/JCO.2006.07.0250

    Article  PubMed  CAS  Google Scholar 

  18. Kennecke H, Yerushalmi R, Woods R, Cheang MCU, Voduc D, Speers CH, Nielsen TO, Gelmon K (2010) Metastatic behavior of breast cancer subtypes. J Clin Oncol 28(20):3271–3277. https://doi.org/10.1200/JCO.2009.25.9820

    Article  PubMed  Google Scholar 

  19. Heitz F, Harter P, Lueck H-J, Fissler-Eckhoff A, Lorenz-Salehi F, Scheil-Bertram S, Traut A, du Bois A (2009) Triple-negative and HER2-overexpressing breast cancers exhibit an elevated risk and an earlier occurrence of cerebral metastases. Eur J Cancer 45(16):2792–2798. https://doi.org/10.1016/j.ejca.2009.06.027

    Article  PubMed  CAS  Google Scholar 

  20. Sperduto PW, Berkey B, Gaspar LE, Mehta M, Curran W (2008) A new prognostic index and comparison to three other indices for patients with brain metastases: an analysis of 1,960 patients in the RTOG database. Int J Radiat Oncol Biol Phys 70(2):510–514. https://doi.org/10.1016/j.ijrobp.2007.06.074

    Article  PubMed  Google Scholar 

  21. Komarnicky LT, Phillips TL, Martz K, Asbell S, Isaacson S, Urtasun R (1991) A randomized phase III protocol for the evaluation of misonidazole combined with radiation in the treatment of patients with brain metastases (RTOG-7916). Int J Radiat Oncol Biol Phys 20(1):53–58. https://doi.org/10.1016/0360-3016(91)90137-S

    Article  PubMed  CAS  Google Scholar 

  22. Sause WT, Scott C, Krisch R, Rotman M, Sneed PK, Janjan N, Davis L, Curran W, Choi KN, Selim H (1993) Phase I/II trial of accelerated fractionation in brain metastases RTOG 85-28. Int J Radiat Oncol Biol Phys 26(4):653–657. https://doi.org/10.1016/0360-3016(93)90284-3

    Article  PubMed  CAS  Google Scholar 

  23. Phillips TL, Scott CB, Leibel SA, Rotman M, Weigensberg IJ (1995) Results of a randomized comparison of radiotherapy and bromodeoxyuridine with radiotherapy alone for brain metastases: report of RTOG trial 89-05. Int J Radiat Oncol Biol Phys 33(2):339–348. https://doi.org/10.1016/0360-3016(95)00168-X

    Article  PubMed  CAS  Google Scholar 

  24. Murray KJ, Scott C, Greenberg HM, Emami B, Seider M, Vora NL, Olson C, Whitton A, Movsas B, Curran W (1997) A randomized phase III study of accelerated hyperfractionation versus standard in patients with unresected brain metastases: a report of the Radiation Therapy Oncology Group (RTOG) 9104. Int J Radiat Oncol Biol Phys 39(3):571–574. https://doi.org/10.1016/S0360-3016(97)00341-6

    Article  PubMed  CAS  Google Scholar 

  25. Sperduto CM, Watanabe Y, Mullan J, Hood T, Dyste G, Watts C, Bender GP, Sperduto P (2008) A validation study of a new prognostic index for patients with brain metastases: the Graded Prognostic Assessment. J Neurosurg 109(6):87–89. https://doi.org/10.3171/JNS/2008/109/12/S14

    Article  PubMed  Google Scholar 

  26. Sperduto PW, Kased N, Roberge D, Xu Z, Shanley R, Luo X, Sneed PK, Chao ST, Weil RJ, Suh J (2012) Effect of tumor subtype on survival and the graded prognostic assessment for patients with breast cancer and brain metastases. Int J Radiat Oncol Biol Phys 82(5):2111–2117. https://doi.org/10.1016/j.ijrobp.2011.02.027

    Article  PubMed  Google Scholar 

  27. Sperduto PW, Kased N, Roberge D, Xu Z, Shanley R, Luo X, Sneed PK, Chao ST, Weil RJ, Suh J (2011) Summary report on the graded prognostic assessment: an accurate and facile diagnosis-specific tool to estimate survival for patients with brain metastases. J Clin Oncol 30(4):419–425. https://doi.org/10.1200/JCO.2011.38.0527

    Article  PubMed  PubMed Central  Google Scholar 

  28. Voduc KD, Cheang MC, Tyldesley S, Gelmon K, Nielsen TO, Kennecke H (2010) Breast cancer subtypes and the risk of local and regional relapse. J Clin Oncol 28(10):1684–1691. https://doi.org/10.1200/JCO.2009.24.9284

    Article  PubMed  Google Scholar 

  29. Parker JS, Mullins M, Cheang MC, Leung S, Voduc D, Vickery T, Davies S, Fauron C, He X, Hu Z (2009) Supervised risk predictor of breast cancer based on intrinsic subtypes. J Clin Oncol 27(8):1160–1167. https://doi.org/10.1200/JCO.2008.18.1370

    Article  PubMed  PubMed Central  Google Scholar 

  30. Hammond MEH, Hayes DF, Dowsett M, Allred DC, Hagerty KL, Badve S, Fitzgibbons PL, Francis G, Goldstein NS, Hayes M (2010) American Society of Clinical Oncology/College of American Pathologists guideline recommendations for immunohistochemical testing of estrogen and progesterone receptors in breast cancer. J Clin Oncol 28(16):2784–2795. https://doi.org/10.1200/JCO.2009.25.6529

    Article  PubMed  PubMed Central  Google Scholar 

  31. Wolff AC, Hammond MEH, Hicks DG, Dowsett M, McShane LM, Allison KH, Allred DC, Bartlett JM, Bilous M, Fitzgibbons P (2013) Recommendations for human epidermal growth factor receptor 2 testing in breast cancer: American Society of Clinical Oncology/College of American Pathologists clinical practice guideline update. J Clin Oncol 31(31):3997–4013. https://doi.org/10.1200/JCO.2013.50.9984

    Article  PubMed  Google Scholar 

  32. Lin NU, Lee EQ, Aoyama H, Barani IJ, Barboriak DP, Baumert BG, Bendszus M, Brown PD, Camidge DR, Chang SM (2015) Response assessment criteria for brain metastases: proposal from the RANO group. Lancet Oncol 16(6):e270-e278. https://doi.org/10.1016/S1470-2045(15)70057-4

    Article  Google Scholar 

  33. Sadikov E, Bezjak A, Yi Q-L, Wells W, Dawson L, Millar B-A, Laperriere N (2007) Value of whole brain re-irradiation for brain metastases—single centre experience. Clin Oncol 19(7):532–538. https://doi.org/10.1016/j.clon.2007.06.001

    Article  CAS  Google Scholar 

  34. Karam I, Nichol A, Woods R, Tyldesley S (2011) Population-based outcomes after whole brain radiotherapy and re-irradiation in patients with metastatic breast cancer in the trastuzumab era. Radiat Oncol 6(1):181. https://doi.org/10.1186/1748-717X-6-181

    Article  PubMed  PubMed Central  Google Scholar 

  35. Cooper J, Steinfeld A, Lerch I (1990) Cerebral metastases: value of reirradiation in selected patients. Radiology 174(3):883–885. https://doi.org/10.1148/radiology.174.3.2305074

    Article  PubMed  CAS  Google Scholar 

  36. Wong WW, Schild SE, Sawyer TE, Shaw EG (1996) Analysis of outcome in patients reirradiated for brain metastases. Int J Radiat Oncol Biol Phys 34(3):585–590. https://doi.org/10.1016/0360-3016(95)02156-6

    Article  PubMed  CAS  Google Scholar 

  37. Akiba T, Kunieda E, Kogawa A, Komatsu T, Tamai Y, Ohizumi Y (2012) Re-irradiation for metastatic brain tumors with whole-brain radiotherapy. Jpn J Clin Oncol 42(4):264–269. https://doi.org/10.1093/jjco/hys007

    Article  PubMed  Google Scholar 

  38. Son CH, Jimenez R, Niemierko A, Loeffler JS, Oh KS, Shih HA (2012) Outcomes after whole brain reirradiation in patients with brain metastases. Int J Radiat Oncol Biol Phys 82(2):e167–e172. https://doi.org/10.1016/j.ijrobp.2011.03.020

    Article  PubMed  Google Scholar 

  39. Ozgen Z, Atasoy BM, Kefeli AU, Seker A, Dane F, Abacioglu U (2013) The benefit of whole brain reirradiation in patients with multiple brain metastases. Radiat Oncol 8(1):1. https://doi.org/10.1186/1748-717X-8-186

    Article  Google Scholar 

  40. Scharp M, Hauswald H, Bischof M, Debus J, Combs SE (2014) Re-irradiation in the treatment of patients with cerebral metastases of solid tumors: retrospective analysis. Radiat Oncol 9(1):4. https://doi.org/10.1186/1748-717X-9-4

    Article  PubMed  PubMed Central  Google Scholar 

  41. Guo S, Balagamwala EH, Reddy C, Elson P, Suh JH, Chao ST (2016) Clinical and radiographic outcomes from repeat whole-brain radiation therapy for brain metastases in the age of stereotactic radiosurgery. Am J Clin Oncol 39(3):288–293. https://doi.org/10.1097/COC.0000000000000051

    Article  PubMed  CAS  Google Scholar 

  42. Logie N, Jimenez R, Pulenzas N, Linden K, Ciafone D, Ghosh S, Xu Y, Lefresne S, Wong E, Son CH (2017) Estimating prognosis at the time of repeat whole brain radiation therapy for multiple brain metastases: The reirradiation score. Adv Radiat Oncol 2(3):381–390. https://doi.org/10.1016/j.adro.2017.05.010

    Article  PubMed  PubMed Central  Google Scholar 

  43. Ricard D, Taillia H, Renard J-L (2009) Brain damage from anticancer treatments in adults. Curr Opin Oncol 21(6):559–565. https://doi.org/10.1097/CCO.0b013e328330c669

    Article  PubMed  CAS  Google Scholar 

  44. Musolino A, Ciccolallo L, Panebianco M, Fontana E, Zanoni D, Bozzetti C, Michiara M, Silini EM, Ardizzoni A (2011) Multifactorial central nervous system recurrence susceptibility in patients with HER2-positive breast cancer. Cancer 117(9):1837–1846. https://doi.org/10.1002/cncr.2577

    Article  PubMed  Google Scholar 

  45. Pestalozzi BC, Holmes E, de Azambuja E, Metzger-Filho O, Hogge L, Scullion M, Láng I, Wardley A, Lichinitser M, Sanchez RIL (2013) CNS relapses in patients with HER2-positive early breast cancer who have and have not received adjuvant trastuzumab: a retrospective substudy of the HERA trial (BIG 1–01). Lancet Oncol 14(3):244–248. https://doi.org/10.1016/S1470-2045(13)70017-2

    Article  PubMed  CAS  Google Scholar 

  46. Mehta AI, Brufsky AM, Sampson JH (2013) Therapeutic approaches for HER2-positive brain metastases: circumventing the blood–brain barrier. Cancer Treat Rev 39(3):261–269. https://doi.org/10.1016/j.ctrv.2012.05.006

    Article  PubMed  CAS  Google Scholar 

  47. Xu Z, Marko NF, Chao ST, Angelov L, Vogelbaum MA, Suh JH, Barnett GH, Weil RJ (2012) Relationship between HER2 status and prognosis in women with brain metastases from breast cancer. Int J Radiat Oncol Biol Phys 82(5):e739–e747. https://doi.org/10.1016/j.ijrobp.2011.06.1968

    Article  PubMed  CAS  Google Scholar 

  48. Wolstenholme V, Hawkins M, Ashley S, Tait D, Ross G (2008) HER2 significance and treatment outcomes after radiotherapy for brain metastases in breast cancer patients. Breast 17(6):661–665. https://doi.org/10.1016/j.breast.2008.04.006

    Article  PubMed  Google Scholar 

  49. Yap Y, Cornelio G, Devi B, Khorprasert C, Kim S, Kim T, Lee S, Park Y, Sohn J, Sutandyo N (2012) Brain metastases in Asian HER2-positive breast cancer patients: anti-HER2 treatments and their impact on survival. Br J Cancer 107(7):1075–1082. https://doi.org/10.1038/bjc.2012.346

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  50. Chargari C, Campana F, Pierga J-Y, Védrine L, Ricard D, Le Moulec S, Fourquet A, Kirova YM (2010) Whole-brain radiation therapy in breast cancer patients with brain metastases. Nat Rev Clin Oncol 7(11):632–640. https://doi.org/10.1038/nrclinonc.2010.119

    Article  PubMed  Google Scholar 

  51. Eichler AF, Kuter I, Ryan P, Schapira L, Younger J, Henson JW (2008) Survival in patients with brain metastases from breast cancer. Cancer 112(11):2359–2367. https://doi.org/10.1002/cncr.23468

    Article  PubMed  CAS  Google Scholar 

  52. Mulvenna P, Nankivell M, Barton R, Faivre-Finn C, Wilson P, McColl E, Moore B, Brisbane I, Ardron D, Holt T (2016) Dexamethasone and supportive care with or without whole brain radiotherapy in treating patients with non-small cell lung cancer with brain metastases unsuitable for resection or stereotactic radiotherapy (QUARTZ): results from a phase 3, non-inferiority, randomised trial. Lancet 388(10055):2004–2014. https://doi.org/10.1016/S0140-6736(16)30825-X

    Article  PubMed  PubMed Central  CAS  Google Scholar 

Download references

Acknowledgements

The authors thank the Cancer Registry, Office of Medical Records, National Taiwan University Hospital, for providing necessary patient information. This study was supported by the following research Grants: MOST 104-2314-B-002-189-MY3, MOST 106-2811-B-002-075 from the Ministry of Science and Technology, Taiwan, and 106-N3652, National Taiwan University Hospital.

Author information

Authors and Affiliations

  1. Institute of Biomedical Engineering, National Taiwan University, Taipei, Taiwan

    Shih-Fan Lai & Tony Hsiang-Kuang Liang

  2. Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan

    Shih-Fan Lai, Yu-Hsuan Chen, Tony Hsiang-Kuang Liang, Che-Yu Hsu, Yen-Sen Lu & Sung-Hsin Kuo

  3. Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan

    Huang-Chun Lien

  4. Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan

    Chiun-Sheng Huang

  5. National Taiwan University Cancer Center, College of Medicine, National Taiwan University, Taipei, Taiwan

    Yen-Sen Lu & Sung-Hsin Kuo

  6. Cancer Research Center, National Taiwan University College of Medicine, Taipei, Taiwan

    Sung-Hsin Kuo

  7. Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei, Taiwan

    Sung-Hsin Kuo

Authors
  1. Shih-Fan Lai
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Yu-Hsuan Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Tony Hsiang-Kuang Liang
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Che-Yu Hsu
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Huang-Chun Lien
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Yen-Sen Lu
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Chiun-Sheng Huang
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Sung-Hsin Kuo
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sung-Hsin Kuo.

Ethics declarations

Conflict of interest

All authors of this paper declare no conflict of interest.

Electronic supplementary material

Below is the link to the electronic supplementary material.

11060_2018_2833_MOESM1_ESM.tif

Supplementary Figure 1. A Flowchart of local management for patients with brain metastases. The stereotactic radiosurgery (SRS) was often used as the first–line treatment for patients with limited number of brain metastases (mostly 1-3 brain metastases) or served as second-line treatment for patients who underwent surgery or whole brain radiotherapy (WBRT). For patients who had large (usually &#x003E;3 cm) solitary brain tumor lesions with mass effect, surgical intervention was usually suggested. For patients who had more than three metastatic lesions, the choice of SRS was dependent on the physician’s decision. The use of WBRT was usually left to patients with multiple brain metastases who had clinical neurological symptoms or progressive intracranial metastasis that were detected by medical imaging. (TIF 470 KB)

Supplementary Table 1 (DOCX 12 KB)

Supplementary Table 2 (DOCX 20 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lai, SF., Chen, YH., Liang, T.HK. et al. The breast graded prognostic assessment is associated with the survival outcomes in breast cancer patients receiving whole brain re-irradiation. J Neurooncol 138, 637–647 (2018). https://doi.org/10.1007/s11060-018-2833-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11060-018-2833-5

Keywords

Search

Navigation