Brief report on the efficacy of sotorasib in KRAS-Mutated NSCLC patients with brain metastases.

INTRODUCTION: Sotorasib has emerged as a treatment option for patients with KRAS-mutated non-small cell lung cancer (NSCLC); however, its effect in patients with brain metastases is not well described. We assessed the intracranial response of sotorasib in a retrospective case series of patients with brain metastases (BMs) at a single institution. METHODS: Patients with KRAS-mutated NSCLC with BMs who received sotorasib at Mass General Brigham Hospitals were included. Patients were stratified into three groups: patients with active BM without local therapy within one month of sotorasib initiation (group 1), patients with active BM with local therapy (surgery or radiation) within one month of sotorasib initiation (group 2), and patients with stable BM (group 3). Intracranial progression-free survival (ICPFS) and overall survival (OS) were explored using Kaplan Meier curves that were compared through log-rank test. RESULTS: Thirty patients were included (five in group 1; seven in group 2; 18 in group 3). Mean age at sotorasib initiation was 60 years. Most (67 %) patients had between one and four BMs at sotorasib initiation. Median ICPFS was three months (95 % CI: 0- 7.7) from start of sotorasib for group 1, two months (0-5.7) for group 2, and 15 months (6.0-24.0) for group 3 (p-value = 0.02). Median OS was four months (1.9-6.1) for group 1, six months (0-13.7) for group 2, and 12 months (3.5-20.5) for group 3 (p-value = 0.13). 57 % of patients experienced intracranial progression, including 44 % of patients who had stable BM at sotorasib initiation. CONCLUSION: While sotorasib may have some intracranial activity, a multidisciplinary approach to BM therapy is still warranted, as are future studies with larger patient samples, controls, and extended follow-up.

The Impact of Tort Reforms on the Neurosurgical Malpractice Environment: A Systematic Review of Literature.

BACKGROUND: Neurosurgeons, especially spine surgeons, have the highest risk of facing a malpractice claim. Average verdicts in spine surgery litigation has been shown to be over USD $1 million/case. This systematic review aimed to clarify the impact of tort reforms on neurosurgical health care environments across the United States, including patient outcomes, practice of defensive medicine, and physician supply aims. METHODS: A systematic literature search was performed using PubMed, Embase, Cochrane, and Web of Science databases until May 13, 2022. Study quality was assessed using the quality assessment tool for studies reporting prevalence data. RESULTS: Five studies (all rated as good quality) were included. Two studies found that in higher-risk state malpractice environments, risk of postoperative complications was higher and odds of nonhome discharge were larger (odds ratio 1.1169, 95% confidence interval 1.139-1.200). One study found that neurosurgeons reported practice of defensive medicine by ordering more imaging in a higher-risk environment, while this was not shown in a study examining imaging rates in different medicolegal environments. One study observed that noneconomic damage caps were associated with a 3.9% increase of physician supply in high-risk specialties. CONCLUSIONS: There was a suggestive association between tort reforms and less practice of defensive medicine among neurosurgeons, improvement in postoperative outcomes in spinal fusion patients, and increase in physician supply. More elaborate studies on the medicolegal environment in neurosurgical practice are needed to give more insight on the current size of the problem that litigation presents in the United States and the effects tort reforms have on neurosurgical health care environments.