Role of Temozolomide in the Treatment of Cancers Involving the Central Nervous System

November 15, 2018

In this article, we review the role of temozolomide in the management of patients with primary brain tumors, brain metastases, leptomeningeal carcinomatosis, and other selected CNS cancers.

Temozolomide has been available to oncologists for over 30 years. During this time, it has become an integral part of standard therapy in patients with high-grade gliomas. Given its ability to traverse the blood-brain barrier, temozolomide has also been evaluated in other cancers that involve the central nervous system (CNS). We review its role in the management of patients with primary brain tumors, brain metastases, leptomeningeal carcinomatosis, and other selected CNS cancers. There is strong evidence that temozolomide is effective in patients with high-grade astrocytomas and oligodendrogliomas. Modest evidence supports its activity in primary CNS lymphomas and aggressive pituitary adenomas. Temozolomide, however, has minimal efficacy in a wide variety of systemic cancers. Given that concentrations of temozolomide in the CNS are only 20% of those in the blood, it is not surprising that it is generally inactive in patients with CNS metastases from solid tumors.

Introduction

Temozolomide was synthesized in the 1980s as a water-soluble imidazotetrazinone that exhibited excellent antineoplastic properties in vitro and in vivo.[1,2] At a pH greater than 7, it spontaneously hydrolyzes to its active form, which is the same active metabolite as in dacarbazine.[3] Its novelty came from the fact that it is an orally bioavailable alkylating agent able to penetrate the blood-brain barrier due to its lipophilic nature.

Temozolomide functions by modifying DNA or RNA through the addition of methyl groups (alkylation) to guanine at the N7 and O6 sites, and to adenine at the O3 site. This causes substitution of thymine for cytosine during DNA replication, which creates a mismatched base pair. This in turn triggers the DNA mismatch repair pathway, which attempts to repair the damage but results in inappropriate DNA crosslinks, G2 arrest, and ultimately, leads to apoptosis (Figure).[4,5] The methyl group temozolomide adds can be repaired by some intracellular DNA repair programs, such as DNA mismatch repair or base excision, or it can be removed by O6-methylguanine-DNA methyltransferase (MGMT), a demethylating enzyme. The amount of methylation temozolomide causes within a cell is important for ensuring catastrophic cell death. Notably, the effect of temozolomide on DNA is independent of whether the cell is irradiated, but temozolomide synergizes with radiation to increase glioma cell death.[6]

Temozolomide received accelerated approval from the US Food and Drug Administration (FDA) in 1999 for treatment-refractory anaplastic astrocytomas.[7] It was later approved by the FDA for newly diagnosed glioblastoma administered concurrently with radiation therapy and for 6 months thereafter based on a phase III study.[8] Since then, it has been a backbone of treatment for both newly diagnosed and recurrent high-grade astrocytomas and oligodendrogliomas.

Although the toxicities of temozolomide are modest compared with other chemotherapy agents, it can have significant side effects. When combined with brain irradiation, 20% of patients develop significant myelosuppression and some develop severe (grade 3/4) lymphopenia, which is long-lasting and associated with reduced survival and poor response to immunologic interventions.[9] Use of temozolomide can also result in constipation, fatigue, and malaise and a small risk of secondary malignancies.

Blood-Brain Barrier Penetration of Temozolomide

Currently, 98% of drugs on the market do not penetrate the blood-brain barrier.[10] Temozolomide’s small size (194 Da) and lipophilicity enhance CNS penetration relative to other alkylating agents. Despite this, the concentration of temozolomide in brain tumor tissue is about 20% of plasma levels.[11] Concentrations in cerebrospinal fluid are similar, although levels may rise to 35% of plasma levels when given concurrently with radiation.[12] Whereas this agent is effective for some tumors, its relatively low concentration in the CNS requires that the cancers being treated are very sensitive to temozolomide.

Many unsuccessful efforts have been made to improve the blood-brain barrier penetration of temozolomide and other systemically administered chemotherapeutic agents. Changing the dosing frequency (dose-dense regimens) or delivery method (through intra-arterial delivery) has resulted in higher toxicity rates without an improvement in patient outcomes.[13-16] Current studies are under way exploring the use of focused ultrasound, regadenoson, and nanoparticles to disrupt the blood-brain barrier or improve drug penetration.[17-19]

Effect of MGMT Status on Temozolomide Sensitivity

The efficacy of temozolomide may be influenced by gene expression within tumor cells. The most important of these is MGMT, a gene that encodes the protein O6-alkylguanine DNA alkyltransferase (AGT) and is responsible for removing methyl groups from DNA at the O6 position. Each AGT molecule is able to irreversibly remove one methyl group, after which it releases the DNA strand and is ubiquitinated and degraded.[20] MGMT activity is regulated in part by promoter methylation, which turns off gene expression. Hypermethylation is frequently observed in some cancers causing MGMT silencing, and demethylation is associated with gene activity.[21]

In glioma clinical trials, epigenetic silencing of MGMT through promoter methylation has been associated with increased DNA double-strand breaks and sensitivity to the alkylating agents BCNU [bis-chloroethylnitrosourea; carmustine] and temozolomide.[8,22,23] In fact, MGMT promoter methylation appears predictive of tumor sensitivity to temozolomide and is also an independent prognostic biomarker, because MGMT methylation is associated with improved survival independently of temozolomide.[24]

Although MGMT methylation in gliomas is a predictive biomarker for temozolomide sensitivity and a prognostic biomarker, this does not appear to be the case in other cancers, such as colorectal cancer and non–small-cell lung cancer.[25-28] The one exception may be diffuse large B-cell lymphoma, in which MGMT methylation may correlate with improved overall survival, although it is not routinely tested in clinical practice and has no effect on treatment selection.[29,30]

Primary Brain Tumors

Astrocytomas

Glioblastoma (grade 4 astrocytoma) is the most common primary brain tumor in adults, affecting over 11,000 people each year in the United States.[31] This cancer is most often diagnosed in older adults and is associated with a median survival of just over 1 year. Although these tumors may appear localized on magnetic resonance imaging, they are virtually never cured with aggressive surgery because tumor cells extend well beyond surgical margins. Radiation therapy is the most beneficial postoperative therapy for this disease, but unfortunately it does not have curative potential. Initial efforts to combine chemotherapy with radiation determined that the nitrosoureas, which cross the blood-brain barrier, were most effective. In prospective, randomized studies, however, the addition of these agents did not result in a substantial survival advantage.[32,33] In 2005, the results of an EORTC/NCIC trial that randomized patients with newly diagnosed glioblastoma to receive either radiation alone or radiation with concurrent and adjuvant temozolomide were published.[8] This unconventional adjuvant trial design included patients with extensive residual tumor in a disease for which temozolomide had insufficient efficacy at recurrence for FDA approval.

Despite flouting conventional adjuvant clinical trial design, this trial convincingly demonstrated a survival advantage from the addition of temozolomide in newly diagnosed glioblastoma. Although the median survival of patients eligible for this trial improved from 12 to 14.6 months with the addition of temozolomide, survival improved from 10% to 26% at 2 years and from 0% to 10% at 5 years.[34]. Additional analysis demonstrated that patients who are MGMT unmethylated derive much less benefit from the addition of temozolomide than those who are MGMT methylated.[34] More recently, the findings of this study were replicated in patients older than age 65 years with newly diagnosed glioblastoma who were treated with a shorter course of radiation.[35] As of 2018, temozolomide remains the only systemically administered pharmaceutical agent documented to provide a survival advantage to patients with glioblastoma.

The annual incidence of anaplastic astrocytomas (grade 3 astrocytoma) is about 1,300 cases/year in the United States, which is 10 times less frequent than that of glioblastoma.[31] As a result, no large prospective, randomized studies exist documenting the magnitude of benefit from adding temozolomide to radiation in this population. The efficacy of temozolomide in patients with recurrent anaplastic astrocytomas, however, was found to be higher than its efficacy in patients with glioblastoma, leading to an approved indication by the FDA.[7] As a result, many patients with newly diagnosed anaplastic astrocytomas, particularly those who are wild type for the isocitrate dehydrogenase (IDH) gene, receive radiation with concurrent and adjuvant temozolomide, just like patients with glioblastoma.

The treatment of patients with grade 2 astrocytomas is more controversial. These tumors may manifest with seizures in patients who are otherwise doing well. In this setting, low-risk patients are often followed closely after surgery without further treatment until there is clear evidence of tumor progression, which may be years later. High-risk patients typically receive treatment with radiation immediately after diagnosis. Risk factors for a poor outcome include age 40 years or older, preoperative tumor size of 5 cm or more, subtotal resection, lack of IDH mutation, lack of 1p/19q codeletion, and elevated mitotic index. The role of chemotherapy in these patients remains controversial. Studies have documented that the PCV regimen, which consists of procarbazine, CCNU [1-(2-Chloroethyl)-3-Cyclohexyl-1-Nitrosourea; lomustine], and vincristine, improves survival following radiation in low-grade gliomas, but the primary benefit appears to be in patients with low-grade oligodendrogliomas.[36] This is not entirely unexpected, given that the PCV regimen has no significant benefit in patients with high-grade astrocytomas.[37] As a result, it might be expected that temozolomide would be a more effective approach to low-grade astrocytomas, although no prospective, randomized study has compared PCV against temozolomide in grade 2 astrocytomas.[38-41] A single-arm study in high-risk, low-grade glioma shows benefit from the combination of temozolomide and radiation.[42] As is the case in glioblastoma, MGMT promoter methylation status may be a marker for response to temozolomide in low-grade glioma, but convincing data are currently lacking.[43]

Oligodendrogliomas

Approximately 1,000 patients per year in the United States are diagnosed with oligodendrogliomas, which are defined by the presence of a 1p/19q codeletion based on current criteria from the World Health Organization. Of these, 70% have low-grade (grade 2) oligodendrogliomas, while 30% have anaplastic oligodendrogliomas (grade 3). Randomized, prospective trials have clearly demonstrated that radiation followed by PCV chemotherapy in patients with grade 2 and 3 oligodendrogliomas leads to a 7-year improvement in survival over radiation alone.[36,44,45] Efficacy of temozolomide monotherapy has also been demonstrated in newly diagnosed and recurrent oligodendrogliomas.[37-40] Currently ongoing is a randomized, prospective trial designed to determine whether radiation followed by PCV or radiation with concurrent and adjuvant temozolomide is the best regimen for patients with recently diagnosed oligodendrogliomas (NCT00887146). This study had a temozolomide-only arm that closed early because it was not as effective as the arms that contained radiation.

Ependymomas

Ependymomas are rare tumors of the cells lining the ventricular cavity. These tumors can occur anywhere along the neuroaxis, but are typically found intracranially in children or within the spinal canal in adults. Treatment usually consists of maximal safe surgical resection, followed by radiation therapy in many cases. Chemotherapy may be used to avoid early irradiation in very young children, but otherwise it has a very limited role in the treatment of ependymomas. There are several case reports of individual responses to temozolomide in the setting of recurrent disease; however, larger retrospective reviews have shown very limited responses.[46-48] Although limited in scope, these data are generally in line with what is known about the resistance of ependymomas to chemotherapy and do not support general use of temozolomide in ependymomas.

Primary CNS lymphoma

Primary CNS lymphoma (PCNSL) is a rare malignancy that comprises 2% of all brain tumors and 2% of all lymphomas. It diffusely involves the brain, and 20% of the time, it is also present in the eyes or spinal fluid. It generally affects older patients. Due to its rarity, randomized clinical trials have been difficult to undertake and complete in this population. Initial treatment attempts focused on whole brain irradiation. The median survival following radiation was only 1 year, however, and the neurologic complications were significant in patients who lived long enough to experience them. As a result, efforts shifted to studying chemotherapy. Typical chemotherapy regimens for lymphomas were not effective, likely secondary to poor blood-brain barrier penetration. Unlike systemic lymphomas, PCNSL is very sensitive to high-dose methotrexate (HD-MTX) with an overall response rate of 74%.[49] Resultantly, HD-MTX has become the base for all standard regimens in newly diagnosed patients. A standard regimen often includes rituximab, with the possible addition of cytarabine, temozolomide, or procarbazine/vincristine.[50] It is unclear whether one of these combinations is superior, and the combination of multiple chemotherapeutic agents can increase toxicity, so a patient’s functional status is an important consideration when selecting a therapeutic regimen.[51] The regimen with temozolomide, in particular, involves HD-MTX plus temozolomide and rituximab followed by consolidation with etoposide and cytarabine. It has shown a complete response rate of 66%, but with grade 3/4 toxicities in more than 55% of participants.[52]

In general, treatment regimens for newly diagnosed PCNSL containing temozolomide are considered in patients who are unable to receive HD-MTX. The most common reason for this is an inadequate creatinine clearance. Whole brain radiation therapy (WBRT) and temozolomide can be efficacious, with a complete response rate of 85% in one small study.[53] In elderly patients for whom WBRT has increased side effects, a retrospective study found HD-MTX plus temozolomide resulted in an overall response rate of 55%, which is comparable to other regimens involving chemotherapy, but with fewer toxicities.[54] Notably, this regimen is associated with a shorter overall survival compared to HD-MTX, procarbazine, vincristine, and cytarabine in a randomized phase II study.[55] This suggests temozolomide may not be the optimal chemotherapeutic agent for PCNSL when other options exist.

Currently, no standard treatment regimen exists for patients with relapsed/refractory PCNSL. Re-treatment typically consists of HD-MTX, if the patient responded to this initially, or WBRT, when possible.[56-58] Several chemotherapy regimens, however, have been used with various efficacy. Temozolomide monotherapy has shown a 31% overall response rate in relapsed/progressive PCNSL using a regimen of 150 mg/m2 for 5 days every 4 weeks in an early phase II trial.[59] The combination of rituximab with temozolomide may also be effective in relapsed/refractory PCNSL, with two retrospective series showing response rates of 53% to 100%.[60,61] Unfortunately, a follow-up prospective study of temozolomide and rituximab was closed for poor accrual and found a response rate of only 14%.[62] Although a regimen including temozolomide can be considered in patients for whom radiation or repeat HD-MTX is not preferred, data to support its efficacy are limited.

Pituitary adenomas/carcinomas

Pituitary adenomas are generally benign tumors that arise from the anterior pituitary and are treated with surgery or pharmacologic treatment. If this initial treatment strategy fails, radiation therapy is used for recurrent/progressive disease. Rarely, aggressive pituitary adenomas or carcinomas continue to progress after standard treatment, in which setting chemotherapy may be considered. Evidence for the use of temozolomide in recurrent pituitary adenoma/carcinomas is limited to case reports and small single-arm studies, the largest of which included 24 patients.[63] In aggregate, however, the response rate to temozolomide monotherapy in aggressive, recurrent pituitary adenoma is 37% to 41%.[64,65] Given this response rate and the lack of other efficacious chemotherapies, the European Society of Endocrinology recommends temozolomide for aggressive pituitary tumors that have failed standard treatment options.[64] Although no clear consensus has been reached on the optimal duration of therapy, generally 6 to 12 months is administered to patients responding to therapy.

Metastases to the central nervous system from systemic cancers

Metastases to the CNS are 10 times more common than primary brain tumors.[66] Approximately 50,000 patients per year in the United States are diagnosed with brain metastases from lung cancer, 9,000 from breast cancer, 3,500 from melanoma, and 1,200 from renal cell cancer. As systemic therapies have improved, the likelihood of relapse within the CNS has increased, due in part to the poor blood-brain barrier penetration of many therapies used in systemic disease. Although WBRT was historically the gold standard for brain metastases, this has changed with the advent of stereotactic radiosurgery and improved neurosurgical techniques. In patients with solitary or oligometastatic disease, surgery in addition to WBRT improves local control and survival over radiation alone.[67] Currently, patients who undergo a surgical resection typically receive stereotactic radiosurgery to their resection cavity rather than WBRT, as survival is similar and the risk of neurocognitive side effects is lower.[68-70] WBRT remains the standard treatment in patients with diffuse brain metastases.

Historically, systemic chemotherapy has been considered inadequate treatment for brain metastases, with only class 3 evidence to support it.[71] Temozolomide is a conceptually attractive cytotoxic chemotherapy for brain metastases given its ability to traverse the blood-brain barrier, potential for synergy with radiation, and relatively benign toxicity profile. As such, it has been studied alone or combined with radiation or other chemotherapies in over 40 clinical trials, primarily in melanoma, lung cancer, and breast cancer. The most promising efficacy data in systemic cancers have been from studies in patients with melanoma with a 13% to 20% response rate.[72,73] This is not unexpected given that temozolomide is an imidazotetrazine derivative of dacarbazine, which has been used extensively in patients with metastatic melanoma. Small series and case reports suggest that the response rate to single-agent temozolomide is less than 10% in neuroendocrine tumors, 5% to 9% in non–small-cell lung cancer, less than 5% in renal cell cancer, and 0% in breast and colon cancer.[74-79]

Given the low response rates to single-agent temozolomide in systemic disease, it is understandable that multiple clinical trials failed to demonstrate significant benefit in brain metastases (Table 1, Table 2). A meta-analysis of seven clinical trials using temozolomide in patients with solid tumor metastasis to the brain demonstrated only very modest effects, and 13 trials evaluating a combination of temozolomide with other antitumor drugs and/or radiation were similarly unimpressive.[80]

The one possible exception is small-cell lung cancer, which is generally more chemosensitive. One single-arm phase II study showed a 22% overall response rate to temozolomide monotherapy in relapsed disease, possibly with more sensitivity in MGMT methylated tumors.[81] Overall, temozolomide has been very disappointing in brain metastases, either alone or in combination with systemic therapies or radiation.

Leptomeningeal carcinomatosis

Leptomeningeal carcinomatosis from systemic cancer is typically treated with radiation, with or without intrathecal or systemic chemotherapy. Temozolomide has been evaluated for leptomeningeal disease given the paucity of cytotoxic agents with CNS penetration. Several case reports have noted response to temozolomide alone, with other chemotherapy, or combined with radiation and chemotherapy.[82-90] A nonrandomized phase II study of temozolomide in adults with leptomeningeal carcinomatosis was stopped early due to slow accrual, however, and showed only two patients with partial response (11%) and one with stable disease (5%).[91] This lack of response is probably explained by the fact that breast and lung cancers, which are resistant to temozolomide, are the most common tumors involving the leptomeninges.

Conclusion

Temozolomide has been evaluated as monotherapy or in combination for a broad range of systemic and CNS cancers. Despite this, the only FDA-approved indications for it are for high-grade primary astrocytomas. Extensive investigation in other cancers has produced very low response rates with minimal effect on survival. Because only a fraction of the systemic drug concentration penetrates the blood-brain barrier, it is understandable that temozolomide is minimally effective for brain metastases from systemic cancers that are not sensitive themselves.

Although temozolomide is currently the only effective chemotherapy agent for patients with gliomas, its efficacy in other tumor types and metastatic disease to the brain has been disappointing. As a result, alternative approaches are generally preferred when treating metastatic CNS cancers.

Financial Disclosure: The authors have no significant financial interest in or other relationship with the manufacturer of any product or provider of any service mentioned in this article.

References:

1. Tisdale MJ. Antitumour imidazotetrazines--XI: effect of 8-carbamoyl-3-methylimidazo[5,1-d]-1,2,3,5-tetrazin-4(3H)-one [CCRG 81045; M and B 39831 NSC 362856] on poly(ADP-ribose) metabolism. Br J Cancer. 1985;52:789-92.

2. Stevens MF, Hickman JA, Langdon SP, et al. Antitumor activity and pharmacokinetics in mice of 8-carbamoyl-3-methyl-imidazo[5,1-d]-1,2,3,5-tetrazin-4(3H)-one (CCRG 81045; M & B 39831), a novel drug with potential as an alternative to dacarbazine. Cancer Res. 1987;47:5846-52.

3. Tsang LL, Quarterman CP, Gescher A, Slack JA. Comparison of the cytotoxicity in vitro of temozolomide and dacarbazine, prodrugs of 3-methyl-(triazen-1-yl)imidazole-4-carboxamide. Cancer Chemother Pharmacol. 1991:27:342-6.

4. Zucchetti M, Catapano CV, Filippeschi S, et al. Temozolomide induced differentiation of K562 leukemia cells is not mediated by gene hypomethylation. Biochem Pharmacol. 1989;38:2069-75.

5. Roos WP, Batista LF, Naumann SC, et al. Apoptosis in malignant glioma cells triggered by the temozolomide-induced DNA lesion O6-methylguanine. Oncogene. 2007;26:186-97.

6. Mrugala MM, Chamberlain MC. Mechanisms of disease: temozolomide and glioblastoma--look to the future. Nat Clin Pract Oncol. 2008;5:476-86.

7. Yung WK, Prados MD, Yaya-Tur R, et al. Multicenter phase II trial of temozolomide in patients with anaplastic astrocytoma or anaplastic oligoastrocytoma at first relapse. Temodal Brain Tumor Group. J Clin Oncol. 1999;17:2762-71.

8. Stupp R, Mason WP, van den Bent MJ, et al; European Organisation for Research and Treatment of Cancer Brain Tumor and Radiotherapy Groups; National Cancer Institute of Canada Clinical Trials Group. Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med. 2005;352:987-96.

9. Diehl A, Yarchoan M, Hopkins A, et al. Relationships between lymphocyte counts and treatment-related toxicities and clinical responses in patients with solid tumors treated with PD-1 checkpoint inhibitors. Oncotarget. 2017;8:114268-80.

10. Pardridge WM. The blood-brain barrier: bottleneck in brain drug development. NeuroRx. 2005;2:3-14.

11. Portnow J, Badie B, Chen M, et al. The neuropharmacokinetics of temozolomide in patients with resectable brain tumors: potential implications for the current approach to chemoradiation. Clin Cancer Res. 2009;15:7092-8.

12. Ostermann S, Csajka C, Buclin T, et al. Plasma and cerebrospinal fluid population pharmacokinetics of temozolomide in malignant glioma patients. Clin Cancer Res. 2004;10:3728-36.

13. Wick W, Engel C, Combs SE, et al. NOA-08 randomized phase III trial of 1-week-on/1-week-off temozolomide versus involved-field radiotherapy in elderly (older than age 65) patients with newly diagnosed anaplastic astrocytoma or glioblastoma (Methusalem). J Clin Oncol. 2009;28(18 suppl):LBA2001.

14. Gilbert MR, Wang M, Aldape KD , et al. Dose-dense temozolomide for newly diagnosed glioblastoma: a randomized phase III clinical trial. J Clin Oncol. 2013;31:4085-91.

15. Muldoon LL, Pagel MA, Netto JP, Neuwelt EA. Intra-arterial administration improves temozolomide delivery and efficacy in a model of intracerebral metastasis, but has unexpected brain toxicity. J Neurooncol. 2016;126:447-54.

16. Shin BJ, Burkhardt JK, Riina HA, Boockvar JA. Superselective intra-arterial cerebral infusion of novel agents after blood-brain disruption for the treatment of recurrent glioblastoma multiforme: a technical case series. Neurosurg Clin N Am. 2012;23:323-9.

17. Wei KC, Chu PC, Wang HY, et al. Focused ultrasound-induced blood-brain barrier opening to enhance temozolomide delivery for glioblastoma treatment: a preclinical study. PLoS One. 2013;8:e58995.

18. Jackson S, George RT, Lodge MA, et al. The effect of regadenoson on the integrity of the human blood-brain barrier, a pilot study. J Neurooncol. 2017;132:513-9.

19. Kumari S, Ahsan SM, Kumar JM, et al. Overcoming blood brain barrier with a dual purpose temozolomide loaded lactoferrin nanoparticles for combating glioma (SERP-17-12433). Sci Rep. 2017;7:6602.

20. Gerson SL. MGMT: its role in cancer aetiology and cancer therapeutics. Nat Rev Cancer. 2004;4:296-307.

21. Esteller M, Hamilton SR, Burger PC, et al. Inactivation of the DNA repair gene O6-methylguanine-DNA methyltransferase by promoter hypermethylation is a common event in primary human neoplasia. Cancer Res. 1999;59:793-7.

22. Esteller M, Garcia-Foncillas J, Andion E, et al. Inactivation of the DNA-repair gene MGMT and the clinical response of gliomas to alkylating agents. N Engl J Med. 2000;343:1350-4.

23. Jaeckle KA, Eyre HJ, Townsend JJ, et al. Correlation of tumor O6 methylguanine-DNA methyltransferase levels with survival of malignant astrocytoma patients treated with bis-chloroethylnitrosourea: a Southwest Oncology Group study. J Clin Oncol. 1998;16:3310-5.

24. Hegi ME, Diserens AC, Gorlia T, et al. MGMT gene silencing and benefit from temozolomide in glioblastoma. N Engl J Med. 2005;352:997-1003.

25. Chen L, Wang Y, Liu F, et al. A systematic review and meta-analysis: association between MGMT hypermethylation and the clinicopathological characteristics of non-small-cell lung carcinoma. Sci Rep. 2018;8:1439.

26. Pietrantonio F, Perrone F, de Braud F, et al. Activity of temozolomide in patients with advanced chemorefractory colorectal cancer and MGMT promoter methylation. Ann Oncol. 2014;25:404-8.

27. Amatu A, Barault L, Moutinho C, et al. Tumor MGMT promoter hypermethylation changes over time limit temozolomide efficacy in a phase II trial for metastatic colorectal cancer. Ann Oncol. 2016;27:1062-7.

28. Calegari MA, Inno A, Monterisi S, et al. A phase 2 study of temozolomide in pretreated metastatic colorectal cancer with MGMT promoter methylation. Br J Cancer. 2017;116:1279-86.

29. Esteller M, Gaidano G, Goodman SN, et al. Hypermethylation of the DNA repair gene O(6)-methylguanine DNA methyltransferase and survival of patients with diffuse large B-cell lymphoma. J Natl Cancer Inst. 2002;94:26-32.

30. Uccella S, Cerutti R, Placidi C, et al. MGMT methylation in diffuse large B-cell lymphoma: validation of quantitative methylation-specific PCR and comparison with MGMT protein expression. J Clin Pathol. 2009;62:715-23.

31. Ostrom QT, Gittleman H, Liao P, et al. CBTRUS statistical report: primary brain and other central nervous system tumors diagnosed in the United States in 2010-2014. Neuro Oncol. 2017;19:v1-v88.

32. Walker MD, Green SB, Byar DP, et al. Randomized comparisons of radiotherapy and nitrosoureas for the treatment of malignant glioma after surgery. N Engl J Med. 1980;303:1323-9.

33. Chang CH, Horton J, Schoenfeld D, et al. Comparison of postoperative radiotherapy and combined postoperative radiotherapy and chemotherapy in the multidisciplinary management of malignant gliomas. A joint Radiation Therapy Oncology Group and Eastern Cooperative Oncology Group Study. Cancer. 1983;52:997-1007.

34. Stupp R, Hegi ME, Mason WP, et al; European Organisation for Research and Treatment of Cancer Brain Tumour and Radiation Oncology Groups; National Cancer Institute of Canada Clinical Trials Group. Effects of radiotherapy with concomitant and adjuvant temozolomide versus radiotherapy alone on survival in glioblastoma in a randomised phase III study: 5-year analysis of the EORTC-NCIC trial. Lancet Oncol. 2009;10:459-66.

35. Perry JR, Laperriere N, O'Callaghan CJ, et al; Trial Investigators. Short-course radiation plus temozolomide in elderly patients with glioblastoma. N Engl J Med. 2017;376:1027-37.

36. Buckner JC, Shaw EG, Pugh SL, et al. Radiation plus procarbazine, CCNU, and vincristine in low-grade glioma. N Engl J Med. 2016;374:1344-55.

37. Medical Research Council Brain Tumor Working Party. Randomized trial of procarbazine, lomustine, and vincristine in the adjuvant treatment of high-grade astrocytoma: a Medical Research Council trial. J Clin Oncol. 2001;19:509-18.

38. Baumert BG, Hegi ME, van den Bent MJ, et al. Temozolomide chemotherapy versus radiotherapy in high-risk low-grade glioma (EORTC 22033-26033): a randomised, open-label, phase 3 intergroup study. Lancet Oncol. 2016;17:1521-32.

39. Wahl M, Phillips JJ, Molinaro AM, et al. Chemotherapy for adult low-grade gliomas: clinical outcomes by molecular subtype in a phase II study of adjuvant temozolomide. Neuro Oncol. 2017;19:242-51.

40. Quinn JA, Reardon DA, Friedman AH, et al. Phase II trial of temozolomide in patients with progressive low-grade glioma. J Clin Oncol. 2003;21:646-51.

41. Pace A, Vidiri A, Galiè E, et al. Temozolomide chemotherapy for progressive low-grade glioma: clinical benefits and radiological response. Ann Oncol. 2003;14:1722-6.

42. Fisher BJ, Hu C, Macdonald DR, et al. Phase 2 study of temozolomide-based chemoradiation therapy for high-risk low-grade gliomas: preliminary results of Radiation Therapy Oncology Group 0424. Int J Radiat Oncol Biol Phys. 2015;91:497-504.

43. Everhard S, Kaloshi G, Crinière E, et al. MGMT methylation: a marker of response to temozolomide in low-grade gliomas. Ann Neurol. 2006;60:740-3.

44. Cairncross G, Wang M, Shaw E, et al. Phase III trial of chemoradiotherapy for anaplastic oligodendroglioma: long-term results of RTOG 9402. J Clin Oncol. 2013;31:337-43.

45. van den Bent MJ, Brandes AA, Taphoorn MJ, et al. Adjuvant procarbazine, lomustine, and vincristine chemotherapy in newly diagnosed anaplastic oligodendroglioma: long-term follow-up of EORTC brain tumor group study 26951. J Clin Oncol. 2013;31:344-50.

46. Gramatzki D, Roth P, Felsberg J, et al. Chemotherapy for intracranial ependymoma in adults. BMC Cancer. 2016;16:287.

47. Rudà R, Bosa C, Magistrello M, et al. Temozolomide as salvage treatment for recurrent intracranial ependymomas of the adult: a retrospective study. Neuro Oncol. 2016;18:261-8.

48. Chamberlain MC, Johnston SK. Temozolomide for recurrent intracranial supratentorial platinum-refractory ependymoma. Cancer. 2009;115:4775-82.

49. Batchelor T, Carson K, O'Neill A, et al. Treatment of primary CNS lymphoma with methotrexate and deferred radiotherapy: a report of NABTT 96-07. J Clin Oncol. 2003;21:1044-9.

50. Holdhoff M, Ambady P, Abdelaziz A, et al. High-dose methotrexate with or without rituximab in newly diagnosed primary CNS lymphoma. Neurology. 2014;83:235-9.

51. Kasenda B, Ferreri AJ, Marturano E, et al. First-line treatment and outcome of elderly patients with primary central nervous system lymphoma (PCNSL)--a systematic review and individual patient data meta-analysis. Ann Oncol. 2015;26:1305-13.

52. Rubenstein JL, Hsi ED, Johnson JL, et al. Intensive chemotherapy and immunotherapy in patients with newly diagnosed primary CNS lymphoma: CALGB 50202 (Alliance 50202). J Clin Oncol. 2013;31:3061-8.

53. Wang Y, Liu B, Xu D, et al. Phase II trial of temozolomide plus concurrent whole-brain radiation followed by TNV regimen as adjuvant therapy for patients with newly diagnosed primary CNS lymphoma. Neurol India. 2013;61:260-4.

54. Omuro AM, Taillandier L, Chinot O, et al. Temozolomide and methotrexate for primary central nervous system lymphoma in the elderly. J Neurooncol. 2007;85:207-11.

55. Omuro A, Chinot O, Taillandier L, et al. Methotrexate and temozolomide versus methotrexate, procarbazine, vincristine, and cytarabine for primary CNS lymphoma in an elderly population: an intergroup ANOCEF-GOELAMS randomised phase 2 trial. Lancet Haematol. 2015;2:e251-9.

56. Plotkin SR, Betensky RA, Hochberg FH, et al. Treatment of relapsed central nervous system lymphoma with high-dose methotrexate. Clin Cancer Res. 2004;10:5643-6.

57. Nguyen PL, Chakravarti A, Finkelstein DM, et al. Results of whole-brain radiation as salvage of methotrexate failure for immunocompetent patients with primary CNS lymphoma. J Clin Oncol. 2005;23:1507-13.

58. Hottinger AF, DeAngelis LM, Yahalom J, Abrey LE. Salvage whole brain radiotherapy for recurrent or refractory primary CNS lymphoma. Neurology. 2007;69:1178-82.

59. Reni M, Zaja F, Mason W, et al. Temozolomide as salvage treatment in primary brain lymphomas. Br J Cancer. 2007;96:864-7.

60. Enting RH, Demopoulos A, DeAngelis LM, Abrey LE. Salvage therapy for primary CNS lymphoma with a combination of rituximab and temozolomide. Neurology. 2004;63:901-3.

61. Wong ET. Salvage therapy for primary CNS lymphoma with a combination of rituximab and temozolomide. Neurology. 2005;64:934; author reply 934.

62. Nayak L, Abrey LE, Drappatz J, et al; North American Brain Tumor Consortium. Multicenter phase II study of rituximab and temozolomide in recurrent primary central nervous system lymphoma. Leuk Lymphoma. 2013;54:58-61.

63. Bengtsson D, Schrǿder HD, Andersen M, et al. Long-term outcome and MGMT as a predictive marker in 24 patients with atypical pituitary adenomas and pituitary carcinomas given treatment with temozolomide. J Clin Endocrinol Metab. 2015;100:1689-98.

64. Raverot G, Burman P, McCormack A, et al. European Society of Endocrinology clinical practice guidelines for the management of aggressive pituitary tumours and carcinomas. Eur J Endocrinol. 2018;178:G1-24.

65. McCormack A, Dekkers OM, Petersenn S, et al. Treatment of aggressive pituitary tumours and carcinomas: results of a European Society of Endocrinology (ESE) survey 2016. Eur J Endocrinol. 2018;178:265-76.

66. Tonn JC, Westphal M, Rutka JT, eds. Oncology of CNS Tumors. Berlin Heidelberg: Springer-Verlag; 2010.

67. Vecht CJ, Haaxma-Reiche H, Noordijk EM, et al. Treatment of single brain metastasis: radiotherapy alone or combined with neurosurgery? Ann Neurol. 1993;33:583-90.

68. Brown PD, Ballman KV, Cerhan JH, et al. Postoperative stereotactic radiosurgery compared with whole brain radiotherapy for resected metastatic brain disease (NCCTG N107C/CEC.3): a multicentre, randomised, controlled, phase 3 trial. Lancet Oncol. 2017;18:1049-60.

69. Aoyama H, Shirato H, Tago M, et al. Stereotactic radiosurgery plus whole-brain radiation therapy vs stereotactic radiosurgery alone for treatment of brain metastases: a randomized controlled trial. JAMA. 2006;295:2483-91.

70. Chang EL, Wefel JS, Hess KR, et al. Neurocognition in patients with brain metastases treated with radiosurgery or radiosurgery plus whole-brain irradiation: a randomised controlled trial. Lancet Oncol. 2009;10:1037-44.

71. Soffietti R, Abacioglu U, Baumert B, et al. Diagnosis and treatment of brain metastases from solid tumors: Guidelines from the European Association of Neuro-oncology (EANO). Neuro Oncol. 2017;19:162-74.

72. Bleehen NM, Newlands ES, Lee SM, et al. Cancer Research Campaign phase II trial of temozolomide in metastatic melanoma. J Clin Oncol. 1995;13:910-3.

73. Middleton MR, Grob JJ, Aaronson N, et al. Randomized phase III study of temozolomide versus dacarbazine in the treatment of patients with advanced metastatic malignant melanoma. J Clin Oncol. 2000;18:158-66.

74. Choong NW, Mauer AM, Hoffman PC, et al. Phase II trial of temozolomide and irinotecan as second-line treatment for advanced non-small cell lung cancer. J Thorac Oncol. 2006;1:245-51.

75. Kouroussis C, Vamvakas L, Vardakis N, et al. Continuous administration of daily low-dose temozolomide in pretreated patients with advanced non-small cell lung cancer: a phase II study. Oncology. 2009;76:112-7.

76. Adonizio CS, Babb JS, Maiale C, et al. Temozolomide in non-small-cell lung cancer: preliminary results of a phase II trial in previously treated patients. Clin Lung Cancer. 2002;3:254-8.

77. Bex A, Kerst J, Mallo H, et al. Extended continuous oral temozolomide in patients with progressive metastatic renal cell carcinoma not responding to interferon alpha 2b. J Chemother. 2005;17:674-8.

78. Trudeau ME, Crump M, Charpentier D, et al. Temozolomide in metastatic breast cancer (MBC): a phase II trial of the National Cancer Institute of Canada - Clinical Trials Group (NCIC-CTG). Ann Oncol. 2006;17:952-6.

79. Khan OA, Ranson M, Michael M, et al. A phase II trial of lomeguatrib and temozolomide in metastatic colorectal cancer. Br J Cancer. 2008;98:1614-8.

80. Zhu W, Zhou L, Qian JQ, et al. Temozolomide for treatment of brain metastases: a review of 21 clinical trials. World J Clin Oncol. 2014;5:19-27.

81. Pietanza MC, Kadota K, Huberman K, et al. Phase II trial of temozolomide in patients with relapsed sensitive or refractory small cell lung cancer, with assessment of methylguanine-DNA methyltransferase as a potential biomarker. Clin Cancer Res. 2012;18:1138-45.

82. Hottinger AF, Favet L, Pache JC, et al. Delayed but complete response following oral temozolomide treatment in melanoma leptomeningeal carcinomatosis. Case Rep Oncol. 2011;4:211-5.

83. Zauderer M, Krug LM, Pietanza MC, O'Rourke D. Leptomeningeal metastases from small cell lung cancer responsive to temozolomide therapy. J Thorac Oncol. 2010;5:1716-7.

84. Ku GY, Krol G, Ilson DH. Successful treatment of leptomeningeal disease in colorectal cancer with a regimen of bevacizumab, temozolomide, and irinotecan. J Clin Oncol. 2007;25:e14-6.

85. Lombardi G, Zustovich F, Della Puppa A, et al. Cisplatin and temozolomide combination in the treatment of leptomeningeal carcinomatosis from ethmoid sinus intestinal-type adenocarcinoma. J Neurooncol. 2011;104:381-6.

86. Lukas RV, Mata-Machado NA, Nicholas MK, et al. Leptomeningeal carcinomatosis in esophageal cancer: a case series and systematic review of the literature. Dis Esophagus. 2015;28:772-81.

87. Salmaggi A, Silvani A, Eoli M, et al. Temozolomide and cisplatin in the treatment of leptomeningeal metastatic involvement from melanoma: a case report. Neurol Sci. 2002;23:257-8.

88. Hoffmann AL, Buhk JH, Strik H. Neoplastic meningitis from breast cancer: feasibility and activity of long-term intrathecal liposomal Ara-C combined with dose-dense temozolomide. Anticancer Res. 2009;29:5191-5.

89. Liu Y. Leptomeningeal carcinomatosis from gastric cancer successfully treated by the intrathecal methotrexate plus temozolomide and simultaneous radiotherapy: case report and literatures review. Cancer Biol Ther. 2017;18:761-4.

90. Subbiah V, Wolff JE. Rapid response to therapy of neurocutaneous melanosis with leptomeningeal melanoma. Pediatr Blood Cancer. 2010;54:180-1.

91. Segura PP, Gil M, Balañá C, et al. Phase II trial of temozolomide for leptomeningeal metastases in patients with solid tumors. J Neurooncol. 2012;109:137-42.

92. Iwamoto FM, Omuro AM, Raizer JJ, et al. A phase II trial of vinorelbine and intensive temozolomide for patients with recurrent or progressive brain metastases. J Neurooncol. 2008;87:85-90.

93. Caraglia M, Addeo R, Costanzo R, et al. Phase II study of temozolomide plus pegylated liposomal doxorubicin in the treatment of brain metastases from solid tumours. Cancer Chemother Pharmacol. 2006;57:34-9.

94. Christodoulou C, Bafaloukos D, Linardou H, et al; Hellenic Cooperative Oncology Group. Temozolomide (TMZ) combined with cisplatin (CDDP) in patients with brain metastases from solid tumors: a Hellenic Cooperative Oncology Group (HeCOG) phase II study. J Neurooncol. 2005;71:61-5.

95. Abrey LE, Olson JD, Raizer JJ, et al. A phase II trial of temozolomide for patients with recurrent or progressive brain metastases. J Neurooncol. 2001;53:259-65.

96. Christodoulou C, Bafaloukos D, Kosmidis P, et al. Phase II study of temozolomide in heavily pretreated cancer patients with brain metastases. Ann Oncol. 2001;12:249-54.

97. Siena S, Crinὸ L, Danova M, et al. Dose-dense temozolomide regimen for the treatment of brain metastases from melanoma, breast cancer, or lung cancer not amenable to surgery or radiosurgery: a multicenter phase II study. Ann Oncol. 2010;21:655-61.

98. Bael TE, Peterson BL, Gollob JA. Phase II trial of arsenic trioxide and ascorbic acid with temozolomide in patients with metastatic melanoma with or without central nervous system metastases. Melanoma Res. 2008;18:147-51.

99. Schadendorf D, Hauschild A, Ugurel S, et al. Dose-intensified bi-weekly temozolomide in patients with asymptomatic brain metastases from malignant melanoma: a phase II DeCOG/ADO study. Ann Oncol. 2006;17:1592-7.

100. Hwu WJ, Lis E, Menell JH, et al. Temozolomide plus thalidomide in patients with brain metastases from melanoma: a phase II study. Cancer. 2005;103:2590-7.

101. Bafaloukos D, Tsoutsos D, Kalofonos H, et al. Temozolomide and cisplatin versus temozolomide in patients with advanced melanoma: a randomized phase II study of the Hellenic Cooperative Oncology Group. Ann Oncol. 2005;16:950-7.

102. Agarwala SS, Kirkwood JM, Gore M, et al. Temozolomide for the treatment of brain metastases associated with metastatic melanoma: a phase II study. J Clin Oncol. 2004;22:2101-7.

103. Larkin JM, Hughes SA, Beirne DA, et al. A phase I/II study of lomustine and temozolomide in patients with cerebral metastases from malignant melanoma. Br J Cancer. 2007;96:44-8.

104. Giorgio CG, Giuffrida D, Pappalardo A, et al. Oral temozolomide in heavily pre-treated brain metastases from non-small cell lung cancer: phase II study. Lung Cancer. 2005;50:247-54.

105. Dziadziuszko R, Ardizzoni A, Postmus PE, et al. Temozolomide in patients with advanced non-small cell lung cancer with and without brain metastases. A phase II study of the EORTC Lung Cancer Group (08965). Eur J Cancer. 2003;39:1271-6.

106. Kouvaris JR, Miliadou A, Kouloulias VE, et al. Phase II study of temozolomide and concomitant whole-brain radiotherapy in patients with brain metastases from solid tumors. Onkologie. 2007;30:361-6.

107. Addeo R, Caraglia M, Faiola V, et al. Concomitant treatment of brain metastasis with whole brain radiotherapy [WBRT] and temozolomide [TMZ] is active and improves quality of life. BMC Cancer. 2007;7:18.

108. Antonadou D, Paraskevaidis M, Sarris G, et al. Phase II randomized trial of temozolomide and concurrent radiotherapy in patients with brain metastases. J Clin Oncol. 2002;20:3644-50.

109. Mikkelsen T, Anderson J, Doyle TJ, et al. Phase I/II dose escalation trial of concurrent temozolomide and whole brain radiation therapy for multiple brain metastasis. J Neurooncol. 2010;100:241-7.

110. Gamboa-Vignolle C, Ferrari-Carballo T, Arrieta Ó, Mohar A. Whole-brain irradiation with concomitant daily fixed-dose temozolomide for brain metastases treatment: a randomised phase II trial. Radiother Oncol. 2012;102:187-91.

111. Cao KI, Lebas N, Gerber S, et al. Phase II randomized study of whole-brain radiation therapy with or without concurrent temozolomide for brain metastases from breast cancer. Ann Oncol. 2015;26:89-94.

112. Atkins MB, Sosman JA, Agarwala S, et al. Temozolomide, thalidomide, and whole brain radiation therapy for patients with brain metastasis from metastatic melanoma: a phase II Cytokine Working Group study. Cancer. 2008;113:2139-45.

113. Hofmann M, Kiecker F, Wurm R, et al. Temozolomide with or without radiotherapy in melanoma with unresectable brain metastases. J Neurooncol. 2006;76:59-64.

114. Margolin K, Atkins B, Thompson A, et al. Temozolomide and whole brain irradiation in melanoma metastatic to the brain: A phase II trial of the Cytokine Working Group. J Cancer Res Clin Oncol. 2002;128:214-8.

115. Cortot AB, Gerinière L, Robinet G, et al; Groupe Lyon-Saint-Etienne d’Oncologie Thoracique; Groupe Français de Pneumo-Cancérologie. Phase II trial of temozolomide and cisplatin followed by whole brain radiotherapy in non-small-cell lung cancer patients with brain metastases: a GLOT-GFPC study. Ann Oncol. 2006;17:1412-7.

116. Sperduto PW, Wang M, Robins HI, et al. A phase 3 trial of whole brain radiation therapy and stereotactic radiosurgery alone versus WBRT and SRS with temozolomide or erlotinib for non-small cell lung cancer and 1 to 3 brain metastases: Radiation Therapy Oncology Group 0320. Int J Radiat Oncol Biol Phys. 2013;85:1312-18.

117. He Q, Bi X, Ren C, et al. Phase II study of the efficacy and safety of high-dose pemetrexed in combination with cisplatin versus temozolomide for the treatment of non-small cell lung cancer with brain metastases. Anticancer Res. 2017;37:4711-6.

118. Hassler MR, Pfeifer W, Knocke-Abulesz TH, et al. Temozolomide added to whole brain radiotherapy in patients with multiple brain metastases of non-small-cell lung cancer: a multicentric Austrian phase II study. Wien Klin Wochenschr. 2013;125:481-6.

119. Pesce GA, Klingbiel D, Ribi K, et al. Outcome, quality of life and cognitive function of patients with brain metastases from non-small cell lung cancer treated with whole brain radiotherapy combined with gefitinib or temozolomide. A randomised phase II trial of the Swiss Group for Clinical Cancer Research (SAKK 70/03). Eur J Cancer. 2012;48:377-84.

120. Chua D, Krzakowski M, Chouaid C, et al. Whole-brain radiation therapy plus concomitant temozolomide for the treatment of brain metastases from non-small-cell lung cancer: a randomized, open-label phase II study. Clin Lung Cancer. 2010;11:176-81.