Computed tomography (CT) and/or magnetic resonance imaging (MRI) demonstrated that 39% of patients diagnosed with stage IV non-small cell lung cancer (NSCLC) presented with de novo brain metastases during the COVID-19 pandemic, higher than historic rates, and many of these patients were asymptomatic for brain metastases. These findings were presented at the European Lung Cancer Virtual Congress 2021 (25-27 March).

Wanyuan Cui of the Department of Medicine (Lung), The Royal Marsden Hospital – NHS Foundation Trust in London, UK and colleagues investigated whether reduced diagnostic procedures and late presentation during the COVID-19 pandemic may have led to late diagnosis of NSCLC and an increase in diagnoses of de novo brain metastases.

The investigators defined the baseline incidence of brain metastases in asymptomatic patients among the consecutive patients with stage IV NSCLC referred to the Royal Marsden Hospital from June to November 2020. This study was a descriptive analysis of prospectively collected data.

Among the 172 patients with NSCLC identified, 95 (55%) patients underwent brain imaging and 77 (45%) patients did not.

More patients undergoing imaging had known molecular variants

Comparison of these cohorts showed that more patients undergoing brain imaging had good ECOG performance status (PS) and received systemic therapy compared to those without brain imaging. In the imaging cohort, 17%, 72%, and 11% of patients were PS 0, 1-2, or 3-4, respectively, whereas in the non-imaging cohort 6%, 48% and 35% were PS 0, 1-2, or 3-4, respectively. PS data were not available (NA) for 10% of patients in the non-imaging cohort.

Patients in the imaging and non-imaging cohort were of similar age; the median age was 70 (range, 34 to 95) versus 74 (range, 47 to 91) years, respectively. Regarding the smoking history in the imaging versus non-imaging cohorts, 21% versus 16% of patients were never smokers, 78% versus 66% were ex- or current-smokers, and data were not available for 1% versus 18% of patients, respectively. In the respective cohorts, 72% versus 58% of patients had adenocarcinoma, 12% versus 16% had squamous cell, 11% versus 5% had other subtypes, and 5% versus 21% had NA subtype data.

A genomic variant was detected in 55% of patients undergoing imaging whereas a variant was observed in 32% of those not receiving imaging; no variant was detected in 29% versus 40%, and variant data were NA for 16% versus 27%, respectively.

Many patients with brain metastases on imaging were asymptomatic

Of the patients undergoing imaging, 37(39%) patients had brain metastases on imaging. Of these, 65% had brain metastases symptoms, and 35% were asymptomatic. In patients with one to five brain metastases, 44% of patients were asymptomatic, as compared to 10% of patients with ≥6 brain metastases (p = 0.07).

Of the 95 patients undergoing brain imaging, 34% had brain metastases symptoms; of those patients, brain metastases were confirmed on imaging in 66% of patients. However, brain metastases were detected on imaging in 21% of asymptomatic patients.

Regarding treatment, 27% of patients with brain metastases received stereotactic radiosurgery (SRS); in this cohort, 5 patients were asymptomatic. Among the remaining 27 patients with brain metastases, 12 were treated with a tyrosine kinase inhibitor (TKI), 4 received palliative radiotherapy, and one patient was monitored. In addition, 8 of these patients were unfit for treatment and 2 died.

No systemic treatment was administered to 30% of patients with brain metastases due to poor ECOG PS in 17 patients and patient wishes in 4 patients.

In the cohort of patients not receiving imaging, systemic treatment was administered to 42% of patients; no systemic treatment was given due to poor ECOG PS in 28 patients, and to patient wishes in 2 patients.

By 1 February 2021, after a median follow-up period of 6.2 months, 57 (33%) patients have died. In patients with baseline brain imaging, there was no difference in survival between patients with de novo brain metastases and those without (hazard ratio [HR] 1.38; 95% confidence interval [CI] 0.72 to 2.97; p = 0.37). In patients with de novo brain metastases, there was no difference in survival between those who were symptomatic versus asymptomatic (HR 0.46; 95% CI 0.16 to 1.30; p = 0.14). There was also no difference in survival between those who had baseline brain imaging and those that did not (HR 0.85; 95% CI 0.50 to 1.46; p = 0.56).


Preliminary survival data for patients with or without brain metastases on brain imaging.

© Wanyuan Cui.

In total 3/10 (30%) patients with brain metastases who received SRS died, compared to 12/27 (44%) patients with brain metastases who did not receive SRS (p = 0.48). In patients with brain metastases who received TKI therapy only, 2/12 (17%) died. In total, 26 (15%) patients underwent subsequent brain imaging, of which 4 (15%) confirmed development of new brain metastases.


During this period of the COVID-19 pandemic, the incidence of de novo brain metastases was higher at 39% in patients with stage IV NSCLC compared with historical rates of 25%, the investigators found.

In addition, many patients (35%) with brain metastases were asymptomatic.

These findings suggest that brain imaging should be considered in all patients with a new diagnosis of stage IV NSCLC. The investigators proposed that further study should be given as to whether early diagnosis and treatment of brain metastases affects survival.

No external funding was disclosed.


180P – Cui W, Milner-Watts C, Saith S, et al. Incidence of brain metastases (BM) in newly diagnosed stage 4 NSCLC during COVID-19. European Lung Cancer Virtual Congress 2021 (25-27 March).