Gastrointestinal cancer and brain metastasis: a rare and ominous sign

Clinical, Radiologic, and Surgical Features of Brain Metastases in Colorectal Cancer. A Strong Correlation Between Surgical Patterns and Outcome

BACKGROUND

Brain metastases (BMs) from colorectal cancer (CRC) are a small percentage of metastatic patients and surgery is considered the best choice to improve survival. While most research has focused on the risk of CRC spreading to the brain, no studies have examined the characteristics of BMs in relation to surgery and outcome. In this study, we evaluate the clinical and radiologic features of BMs from CRC patients who underwent surgery and analyze their outcomes.

METHODS

The study is a retrospective observational analysis that included a cohort of 31 patients affected by CRC surgically-treated for their related BMs. For all patients, clinical and surgical data (number, site, side, tumor and edema volume, and morphology) were recorded.

RESULTS

Analysis found that synchronous diagnosis and lesion morphology, particularly cystic versus solid, had the most significant impact on survival (6 vs. 22 months, P = 0.04). To compare BMs with cystic morphology to those with solid morphology, a multivariate analysis was conducted. No significant differences were observed between the 2 groups in terms of age, sex, clinical onset, or performance status. The analysis revealed no significant differences in localization with regard to site, tumor and edema volume, biology, or complications rate.

CONCLUSIONS

BMs derived from CRC have a significantly different prognosis depending on whether they present as a solid or cystic pattern. Although solid pattern is more common, cystic BMs in this tumor type are less frequent and are associated with a poorer prognosis, regardless of molecular expression, location, size, and adjuvant treatment.

Primary coexisting adenocarcinoma of the colon and neuroendocrine tumor of the duodenum: A case report and review of the literature

BACKGROUND

Neuroendocrine tumors (NETs) arise from the body's diffuse endocrine system. Coexisting primary adenocarcinoma of the colon and NETs of the duodenum (D-NETs) is a rare occurrence in clinical practice. The classification and treatment criteria for D-NETs combined with a second primary cancer have not yet been determined.

CASE SUMMARY

We report the details of a case involving female patient with coexisting primary adenocarcinoma of the colon and a D-NET diagnosed by imaging and surgical specimens. The tumors were treated by surgery and four courses of chemotherapy. The patient achieved a favorable clinical prognosis.

CONCLUSION

Coexisting primary adenocarcinoma of the colon and D-NET were diagnosed by imaging, laboratory indicators, and surgical specimens. Surgical resection combined with chemotherapy was a safe, clinically effective, and cost-effective treatment.

Spatial transcriptomics of gastric cancer brain metastasis reveals atypical vasculature strategies with supportive immune profiles

Background

Gastric cancer brain metastasis (GCBM) represents a rare but highly aggressive malignancy. Metastatic cancer cells are highly heterogeneous and differentially remodels brain vasculature and immune microenvironments, which affects the treatment effectiveness and patient outcome. This study aimed to investigate the spatial interactions among different cell components, especially the vasculature system and the brain microenvironment of GCBM patients.

Methods

We used digital spatial profiling to examine 140 regions composing tumor, immune, and brain tissues from three GCBM patients. Transcriptomic data with spatial information were analyzed for tissue areas related to different blood recruitment strategies. For validation, independent analysis of patient bulk transcriptomic data and in vivo single-cell transcriptomic data were performed.

Results

Angiogenesis and blood vessel co-option co-existed within the same GCBM lesion. Tumors with high epithelial-mesenchymal transition and an enhanced transcriptomic gene signature composed of CTNNB1, SPARC, VIM, SMAD3, SMAD4, TGFB1, TGFB2, and TGFB3 were more prone to adopt blood vessel co-option than angiogenesis. Enriched macrophage infiltration, angiogenic chemokines, and NAMPT were found in angiogenic areas, while increased T cells, T cell activating cytokines, and reduced NAMPT were found in vessel co-option regions. Spatially, angiogenesis was enriched at the tumor edge, which showed higher DMBT1 expression than the tumor center.

Conclusions

This study mapped the orchestrated spatial characteristics of tumor and immunological compositions that support the conventional and atypical vascularization strategies in GCBM. Our data provided molecular insights for more effective combinations of anti-vascular and immune therapies.

Clinical and molecular characteristics of patients with brain metastasis secondary to pancreatic ductal adenocarcinoma

BACKGROUND

The prognosis for patients with pancreatic ductal adenocarcinoma (PDAC) is poor. Secondary brain metastasis (Br-M) occurs in less than 1% of patients. Clinical characteristics and molecular alterations have not been characterized in this rare patients' subset.

MATERIALS AND METHODS

The Foundry software platform was used to retrospectively query electronic health records for patients with Br-M secondary to PDAC from 2005 to 2023; clinical, molecular, and overall survival (OS) data were analyzed.

RESULTS

Br-M was diagnosed in 44 patients with PDAC. Median follow-up was 78 months; median OS from initial PDAC diagnosis was 47 months. Median duration from PDAC diagnosis to Br-M detection was 24 months; median OS from Br-M diagnosis was 3 months. At Br-M diagnosis, 82% (n = 36) of patients had elevated CA19-9. Lung was the most common preexisting metastatic location (71%) with Br-M, followed by liver (66%). Br-M were most frequently observed in the frontal lobe (34%, n = 15), cerebellar region (23%, n = 10), and leptomeninges (18%, n = 8). KRAS mutations were detected in 94.1% (n = 16) of patients who had molecular data available (n = 17) with KRASG12V being the most frequent subtype 47% (n = 8); KRASG12D in 29% (n = 5); KRASG12R in 18% (n = 3). Patients who underwent Br-M surgical resection (n = 5) had median OS of 8.6 months, while median OS following stereotactic radiosurgery only (n = 11) or whole-brain radiation only (n = 20) was 3.3 and 2.8 months, respectively.

CONCLUSION

Br-M is a late PDAC complication, resulting in an extremely poor prognosis especially in leptomeningeal disease. KRAS was mutated in 94.1% of the patients and the KRASG12V subtype was prevalent.

A Nomogram Based on Clinicopathological Characteristics for Estimating the Risk of Brain Metastasis from Advanced Gastric Cancer: A Multi-Center Retrospective Clinical Study

Purpose

Although brain metastasis (BM) from gastric cancer (GC) is relatively uncommon, its incidence has been increasing owing to advancements in treatment modalities. Unfortunately, patients diagnosed with BM from gastric cancer have poor life expectancy. Our study aims to establish a predictive model for brain metastasis in advanced gastric cancer patients, thus enabling the timely diagnosis of brain metastasis.

Patients and Methods

The clinicopathological features of a cohort which included 40 GC patients with brain metastasis, 32 of whom from the First Affiliated Hospital of Nanchang University, 2 from Gaoxin Branch of the First Affiliated Hospital of Nanchang University, remaining 6 from Anyang District Hospital, and 80 non-metastatic advanced GC patients from the First Affiliated Hospital of Nanchang University between 2018 and 2022. Data were retrospectively analyzed.

Results

Age, tumor size, differentiation, lymph node grade, tumor location, Lauren classification, liver metastasis, carbohydrate antigen 199 (CA199), lactate dehydrogenase (LDH), and human epidermal growth factor receptor 2 (Her-2) were associated with BM. A nomogram integrated with nine risk factors (tumor size, differentiation, lymph node grade, tumor location, Lauren classification, liver metastasis, CA-199, LDH, and Her-2) showed good performance (Area Under Curve 0.95, 95% CI: 0.91-0.98).

Conclusion

We developed and validated a nomogram that achieved individualized prediction of the possibility of BM from GC. This model enables personalized imaging review schedules for timely brain metastasis detection in advanced gastric cancer patients.

Survival after Stereotactic Radiosurgery in the Era of Targeted Therapy: Number of Metastases No Longer Matters

Randomised control trial data support the use of stereotactic radiosurgery (SRS) in up to 4 brain metastases (BMs), with non-randomised prospective data complementing this for up to 10 BMs. There is debate in the neuro-oncology community as to the appropriateness of SRS in patients with >10 BMs. We present data from a large single-centre cohort, reporting survival in those with >10 BMs and in a >20 BMs subgroup. A total of 1181 patients receiving SRS for BMs were included. Data were collected prospectively from the time of SRS referral. Kaplan-Meier graphs and logrank tests were used to compare survival between groups. Multivariate analysis was performed using the Cox proportional hazards model to account for differences in group characteristics. Median survival with 1 BM (n = 379), 2-4 BMs (n = 438), 5-10 BMs (n = 236), and >10 BMs (n = 128) was 12.49, 10.22, 10.68, and 10.09 months, respectively. Using 2-4 BMs as the reference group, survival was not significantly different in those with >10 BMs in either our univariable (p = 0.6882) or multivariable analysis (p = 0.0564). In our subgroup analyses, median survival for those with >20 BMs was comparable to those with 2-4 BMs (10.09 vs. 10.22 months, p = 0.3558). This study contributes a large dataset to the existing literature on SRS for those with multi-metastases and supports growing evidence that those with >10 BMs should be considered for SRS.

Predicting Survival with Brain Metastases in the Stereotactic Radiosurgery Era: are Existing Prognostic Scores Still Relevant? Or Can we do Better?

Predicting survival is essential to tailoring treatment for patients diagnosed with brain metastases. We have evaluated the performance of widely used, validated prognostic scoring systems (Graded Prognostic Assessment and diagnosis-specific Graded Prognostic Assessment) in over 1000 'real-world' patients treated with stereotactic radiosurgery to the brain, selected according to National Health Service commissioning criteria. Survival outcomes from our dataset were consistent with those predicted by the prognostic systems, but with certain cancer subtypes showing a significantly better survival than predicted. Although performance status remains the simplest tool for prediction, total brain tumour volume emerges as an independent prognostic factor, and a new, improved, prognostic scoring system incorporating this has been developed.

The Role of Stereotactic Radiosurgery in Patients With Brain Metastases From Colorectal Cancers

BACKGROUND AND OBJECTIVES

The role of stereotactic radiosurgery (SRS) in patients with brain metastases (BMs) from colorectal cancers (CRCs) has not been established. The authors present a single-institution experience of patients with CRC who underwent SRS with metastatic brain spread.

METHODS

We retrospectively analyzed 111 patients with metastatic CRC (64 female, 57.7%), with 449 BMs treated with Gamma Knife SRS between 2000 and 2022. The median age during SRS was 63 years (range: 28-86), and the median Karnofsky Performance Scale was 80 (range: 60-100). The primary sites were colon (85 patients, 76.6%) and rectal (26 patients, 23.4%). Three patients underwent hypofractionated SRS (3 sessions) with a median margin dose of 27 Gy (range: 27-30). All other patients underwent single-session SRS with a median margin dose of 18 Gy (range: 13-20).

RESULTS

The median patient survival after SRS was 7 months (range: 1-174). Ninety-eight (88.3%) patients expired at last follow-up and 15 patients (15.3%) died related to progressive intracranial disease. A Karnofsky Performance Scale of <80 at SRS presentation ( P = .02, hazard ratio [HR]: 0.6, 95% CI: 0.4-0.9) and no previous surgical resection ( P < .01, HR: 0.4, 95% CI: 0.3-0.7) were associated with inferior overall survival using multivariate analysis. Seventeen patients (15.3%) had documented local tumor progression after SRS, at a median time of 7 months (range: 3-34) between SRS and progression. Twenty-six patients (23.4%) developed new BMs at a median of 5 months (range: 2-26) between SRS and new tumor detection. Less than three BMs at SRS presentation ( P = .02, HR: 2.6, 95% CI: 1.2-5.6) were associated with better distant tumor control on multivariate analysis. The incidence of adverse radiation effects was 5.4%.

CONCLUSION

SRS effectively controls BMs from CRC with low risk of treatment-related toxicity. During follow-up, the development of additional metastases can be safely treated by repeat SRS.

Construction and validation of machine learning models for predicting distant metastases in newly diagnosed colorectal cancer patients: A large-scale and real-world cohort study

BACKGROUND

More accurate prediction of distant metastases (DM) in patients with colorectal cancer (CRC) would optimize individualized treatment and follow-up strategies. Multiple prediction models based on machine learning have been developed to assess the likelihood of developing DM.

METHODS

Clinicopathological features of patients with CRC were obtained from the National Cancer Center (NCC, China) and the Surveillance, Epidemiology, and End Results (SEER) database. The algorithms used to create the prediction models included random forest (RF), logistic regression, extreme gradient boosting, deep neural networks, and the K-Nearest Neighbor machine. The prediction models' performances were evaluated using receiver operating characteristic (ROC) curves.

RESULTS

In total, 200,958 patients, 3241 from NCC and 197,717 CRC from SEER were identified, of whom 21,736 (10.8%) developed DM. The machine-learning-based prediction models for DM were constructed with 12 features remaining after iterative filtering. The RF model performed the best, with areas under the ROC curve of 0.843, 0.793, and 0.806, respectively, on the training, test, and external validation sets. For the risk stratification analysis, the patients were separated into high-, middle-, and low-risk groups according to their risk scores. Patients in the high-risk group had the highest incidence of DM and the worst prognosis. Surgery, chemotherapy, and radiotherapy could significantly improve the prognosis of the high-risk and middle-risk groups, whereas the low-risk group only benefited from surgery and chemotherapy.

CONCLUSION

The RF-based model accurately predicted the likelihood of DM and identified patients with CRC in the high-risk group, providing guidance for personalized clinical decision-making.

The relationship between brain metastasis and HER2 expression status in gastric cancer

BACKGROUND

Brain metastasis (BM) in gastric cancer (GC) is underestimated, and human epidermal growth factor receptor 2 (HER2) overexpression is a durable poor prognostic factor. We explored the relationship between the two and made a survival analysis.

METHODS

HER2 expression and BM status were collected from GC patients who were diagnosed between December 2009 and May 2021. We collected GC patients diagnosed between 2010 and 2016 from the SEER database. The primary endpoint was survival from the diagnosis of BM. Multivariable logistic regression was used to determine potential risk factors of BM at diagnosis in SEER database. Survival analysis was performed using the Kaplan-Meier method.

RESULT

There were 513 HER2-positive GC patients, including 16 (3.1%) with BM. Among 38 brain metastasis GC patients we collected, 16 (42.1%) patients were HER2 positive. We collected 34,199 GC patients from the SEER database and there were 260 (0.76%) patients with BM at diagnosis. GC patients that are male, white, of younger age, with primary lesions located in the proximal stomach or with distant lymph nodes, liver, bone, or lung metastasis are more likely to develop BM. The median overall survival time from diagnosis of BM was 12.73 months, and the survival time from brain metastasis of HER2-positive patients was numerically shorter, though the difference was not significant (5.30 months vs.16.13 months, P = 0.28.) CONCLUSION: The incidence of BM in patients with HER2-positive gastric cancer is 4.08 times higher than that in general patients. The median overall survival time from BM is shorter for HER2-positive patients.

Role of radiotherapy in the management of brain oligometastases

The management of patients with brain oligometastases is complex and relies on specific reasoning compared to extracranial oligometastases. The levels of evidence are still low because patients with brain oligometastases are frequently excluded from randomized clinical trials. Stereotactic radiotherapy should be preferred in this indication over whole brain irradiation, both for patients with metastases in place and for those who have undergone surgery. The decision of local treatment and its timing must be a multidisciplinary reflection taking into account the histological and molecular characteristics of the tumor as well as the intracranial efficacy of the prescribed systemic treatments. Great caution must be observed when using stereotactic radiotherapy and concomitant systemic treatments because interactions are still poorly documented. We present the recommendations of the French society of radiation oncology on the management of brain oligometastatic patients with radiotherapy.

Prognostic Indicators for Intracranial Metastases from Pancreatic Cancer: A Population-Based Retrospective Surveillance, Epidemiology, and End Results Database Analysis

OBJECTIVE

The natural history, treatment options, and clinical outcomes of pancreatic metastases to the brain remain largely unknown. Here, we seek to investigate characteristics that influence OS in pancreatic metastases to the brain.

METHODS

This is a population-based retrospective study of OS in 508 patients with pancreatic metastases to the brain using the SEER database. Univariate and multivariate Cox regression analyses were utilized, and a predictive nomogram was developed.

RESULTS

There were 508 patients identified for this study, with a median OS of 2 months. In the univariate analysis, patients older than 65 years had significantly reduced OS (P < 0.001). Patients with liver metastases (P < 0.001) and liver and lung metastases (P < 0.001) exhibited significantly reduced OS. Treatment of the primary tumor with chemotherapy only (P < 0.001), radiation only (P = 0.01), radiation and chemotherapy (P < 0.001), and surgery only (P = 0.01) were associated with increased OS. Resection of a distant metastasis site (P = 0.009) and of a brain metastasis (P = 0.03) were associated with increased OS. In the multivariable analysis, factors that remained significant included patient age (P = 0.01), liver metastases (P < 0.001), liver and lung metastases (P < 0.001), treatment with chemotherapy (P < 0.001), treatment with radiation and chemotherapy (P < 0.001), and treatment with surgery and chemotherapy (P < 0.001). The nomogram had a C-index of 0.766, suggesting congruence between the findings on the nomogram and the results in the internal verification.

CONCLUSIONS

Median OS is influenced by age, multiorgan metastases, and treatment of the primary tumor. These data highlight the marginal benefit of treatment, yet improved quality of life (QOL) remains to be elucidated.

Concomitant radiosurgical and targeted oncological treatment improves the outcome of patients with brain metastases from gastrointestinal cancer

BACKGROUND

So far, only limited studies exist that evaluate patients with brain metastases (BM) from GI cancer and associated primary cancers who were treated by Gamma Knife Radiosurgery (GKRS) and concomitant immunotherapy (IT) or targeted therapy (TT).

METHODS

Survival after GKRS was compared to the general and specific Graded Prognostic Assessment (GPA) and Score Index for Radiosurgery (SIR). Further, the influence of age, sex, Karnofsky Performance Status Scale (KPS), extracranial metastases (ECM) status at BM diagnosis, number of BM, the Recursive Partitioning Analysis (RPA) classes, GKRS1 treatment mode and concomitant treatment with IT or TT on the survival after GKRS was analyzed. Moreover, complication rates after concomitant GKRS and mainly TT treatment are reported.

RESULTS

Multivariate Cox regression analysis revealed IT or TT at or after the first Gamma Knife Radiosurgery (GKRS1) treatment as the only significant predictor for overall survival after GKRS1, even after adjusting for sex, KPS group, age group, number of BM at GKRS1, RPA class, ECM status at BM diagnosis and GKRS treatment mode. Concomitant treatment with IT or TT did not increase the rate of adverse radiation effects. There was no significant difference in local BM progression after GKRS between patients who received IT or TT and patients without IT or TT.

CONCLUSION

Good local tumor control rates and low rates of side effects demonstrate the safety and efficacy of GKRS in patients with BM from GI cancers. The concomitant radiosurgical and targeted oncological treatment significantly improves the survival after GKRS without increasing the rate of adverse radiation effects. To provide local tumor control, radiosurgery remains of utmost importance in modern GI BM management.

Gastric Cancer With Brain Metastasis: A Case Report

Although gastric cancer is one of the most common types of cancer worldwide, it rarely involves metastasis to the brain. Brain metastases can present with non-specific neurological symptoms such as focal neurological deficits, personality changes, or ataxia. Unfortunately, once brain metastasis is confirmed using imaging, the average life span is approximately two to four months. However, surgical and nonsurgical interventions have been able to improve quality and extend life to up to a year in patients living with gastric cancer that has metastasized to the brain. We report the diagnosis and surgical management of a 73-year-old female who presented with brain metastasis from gastric cancer. After a combination of radiation therapy, surgical management, and pharmacological intervention, the metastasis was successfully removed from the brain, as indicated by a negative CT and MRI on a four-year follow-up.

Outcomes Following Early Postoperative Adjuvant Radiosurgery for Brain Metastases

Importance

Adjuvant stereotactic radiosurgery (SRS) enhances the local control of resected brain metastases (BrM). However, the risks of local failure (LF) and potential for posttreatment adverse radiation effects (PTRE) after early postoperative adjuvant SRS have not yet been established.

Objective

To evaluate whether adjuvant SRS delivered within a median of 14 days after surgery is associated with improved LF without a concomitant increase in PTRE.

Design, Setting, and Participants

This prospective cohort study examines a clinical workflow (RapidRT) that was implemented from 2019 to 2022 to deliver SRS to surgical patients within a median of 14 days, ensuring all patients were treated within 30 days postoperatively. This prospective cohort was compared with a historical cohort (StanRT) of patients with BrM resected between 2013 and 2019 to assess the association of the RapidRT workflow with LF and PTRE. The 2 cohorts were combined to identify optimal SRS timing, with a median follow-up of 3.3 years for survivors.

Exposure

Timing of adjuvant SRS (14, 21, and 30 days postoperatively).

Main Outcomes and Measures

LF and PTRE, according to modified Response Assessment in Neuro-Oncology Brain Metastases criteria.

Results

There were 438 patients (265 [60.5%] female patients; 23 [5.3%] Asian, 27 [6.2%] Black, and 364 [83.1%] White patients) with a mean (SD) age of 62 (13) years; 377 were in the StanRT cohort and 61 in the RapidRT cohort. LF and PTRE rates at 1 year were not significantly different between RapidRT and StanRT cohorts. Timing of SRS was associated with radiographic PTRE. Patients receiving radiation within 14 days had the highest 1-year PTRE rate (18.08%; 95% CI, 8.31%-30.86%), and patients receiving radiation between 22 and 30 days had the lowest 1-year PTRE rate (4.10%; 95% CI, 1.52%-8.73%; P = .03). LF rates were highest for patients receiving radiation more than 30 days from surgery (10.65%; 95% CI, 6.90%-15.32%) but comparable for patients receiving radiation within 14 days, between 15 and 21 days, and between 22 and 30 days (≤14 days: 5.12%; 95% CI, 0.86%-15.60%; 15 to ≤21 days: 3.21%; 95% CI, 0.59%-9.99%; 22 to ≤30 days: 6.58%; 95% CI, 3.06%-11.94%; P = .20).

Conclusions and Relevance

In this cohort study of adjuvant SRS timing following surgical resection of BrM, the optimal timing for adjuvant SRS appears to be within 22 to 30 days following surgery. The findings of this study suggest that this timing allows for a balanced approach that minimizes the risks associated with LF and PTRE.

Incidence, clinicopathological characteristics, and therapeutic strategy for gastric cancer patients with metastasis to the central nervous system

AIM

This study aimed to analyze the clinicopathologic features and treatment outcomes of central nervous system (CNS) metastasis from gastric cancer.

METHODS

A total of 419 patients diagnosed with unresectable advanced or recurrent gastric cancer at Kochi Medical School between January 2007 and December 2021 were evaluated. Data of patients were reviewed, and clinicopathological information and survival outcomes of those with CNS metastases were compared to patients without CNS metastases.

RESULTS

In total, 12/419 (2.9%) patients (median age: 66.5 years [range, 41-82 years]) were diagnosed with CNS metastasis from gastric cancer. Eleven had diffuse-type gastric cancer which was significantly more common than in those without CNS metastasis (91% vs. 61%, p = .034). Human epidermal growth factor receptor 2 status was positive in one of the 12 patients. The median survival time was significantly lower for patients with CNS metastasis than for those without CNS metastasis (1.8 months vs. 11.4 months, p < .001). The median survival time for patients who underwent surgical resection, radiation, or chemotherapy for CNS metastasis was significantly higher than those who received only best supportive care (3.5 months vs. .6 months; p = .007).

CONCLUSIONS

CNS metastasis was found in 2.9% (12/419) of patients with unresectable advanced or recurrent gastric cancer. Diffuse-type histology was a risk factor for CNS metastasis. Multidisciplinary treatment, including surgical resection, radiation treatment, or chemotherapy, for CNS metastasis from gastric cancer may benefit selected patients.

Very rare metastatic phenomena of biliary tract cancer to the cerebellum: A case report and review of the literature

INTRODUCTION AND IMPORTANCE

The occurrence of brain metastasis due to cholangiocarcinoma is an exceedingly uncommon phenomenon, documented in only a few numbers of published cases. Recent studies indicated an incidence rate of just 0.15 % for brain metastases in connection with this condition, which was also linked to a reduced survival rate.

CASE PRESENTATION

A 58-year-old woman with a history of hepatobiliary cholangiocarcinoma presented with a recent onset of unsteady walking, dizziness, vomiting, and worsening occipital headaches. Her medical history included successful chemotherapy treatment for her cholangiocarcinoma. Neurological examination revealed right-sided cerebellar deficits, and imaging indicated a sizable lesion in the right cerebellar hemisphere with surrounding vasogenic edema. A PET scan revealed a liver lesion but no other significant abnormalities. The recommended approach was surgical excision of the cerebellar lesion to relieve symptoms, halt deterioration, and obtain a tissue sample for analysis. After comprehensive discussions with the patient and her family, they opted for the surgical procedure.

CLINICAL DISCUSSION

The major contributors to brain metastases include lung cancers, breast cancers, testicular cancers, melanomas, and renal tumors. In contrast, brain metastases originating from gastrointestinal cancers are less frequent, accounting for fewer than 4 % of cases, with notable impact on 1 % of colorectal cancers, 0.62 % of gastric cancers, and 0.33 % of pancreatic cancers. However, brain metastases are extremely rare.

CONCLUSION

This study underscores the significance of anticipating and identifying brain metastases in biliary tract cancers, even in the face of their low incidence and the limited amount of available literature on the subject.

Decision-Making in Clival Mass Lesions: Risk Factors for Malignant Disease and an Illustrative Case Example

Introduction  Clival tumors are rare and heterogeneous. Although some benign prototypical sellar lesions may present as clival tumors, the likelihood of malignant disease is higher. Here we define a novel algorithm for the workup and management of clival masses through an illustrative case of colorectal adenocarcinoma metastasis to the clivus. Methods  In this case report, the best practice guidelines for managing clival masses are described through a literature review and refined by senior author consensus. We conducted a focused systematic review to characterize the present case in the context of clival metastasis from gastrointestinal malignancy. Results  An 83-year-old woman presented with 4 weeks of headaches and blurry vision. Examination revealed partial right abducens and left oculomotor palsies. Magnetic resonance imaging (MRI) identified a large, weakly enhancing sellar and clival mass with sphenoid sinus extension. An aggressive subtotal endoscopic endonasal resection was performed with removal of all sphenoid, clival, and sellar disease without cavernous sinus wall resection. Pathology confirmed colorectal adenocarcinoma; computed tomography (CT) imaging identified an ascending colon mass with metastases to the liver and mesenteric nodes. Palliative oncologic therapies were recommended, but she elected hospice, and died 3 months after initial presentation. Gastrointestinal clival metastases are exceedingly rare among sellar and clival pathologies, with eight prior cases reported, most of which presented with diplopia from abducens nerve involvement. Conclusion  Clival masses are uncommon skull base lesions that are associated with more aggressive diseases. We present a consolidated framework for decision-making in these challenging patients, alongside an unusual case example that illustrates the importance of increased suspicion for malignant clinical entities in this setting.

Local Control and Survival Outcomes After Stereotactic Radiosurgery for Brain Metastases From Gastrointestinal Primaries: An International Multicenter Analysis

BACKGROUND

There are limited data regarding outcomes for patients with gastrointestinal (GI) primaries and brain metastases treated with stereotactic radiosurgery (SRS).

OBJECTIVE

To examine clinical outcomes after SRS for patients with brain metastases from GI primaries and evaluate potential prognostic factors.

METHODS

The International Radiosurgery Research Foundation centers were queried for patients with brain metastases from GI primaries managed with SRS. Primary outcomes were local control (LC) and overall survival (OS). Kaplan-Meier analysis was used for univariate analysis (UVA) of prognostic factors. Factors significant on UVA were evaluated with a Cox multivariate analysis proportional hazards model. Logistic regressions were used to examine correlations with RN.

RESULTS

We identified 263 eligible patients with 543 brain metastases. Common primary sites were rectal (31.2%), colon (31.2%), and esophagus (25.5%) with a median age of 61.6 years (range: 37-91.4 years) and a median Karnofsky performance status (KPS) of 90% (range: 40%-100%). One-year and 2-year LC rates were 83.5% (95% CI: 78.9%-87.1%) and 73.0% (95% CI: 66.4%-78.5%), respectively. On UVA, age >65 years ( P = .001), dose <20 Gy ( P = .006) for single-fraction plans, KPS <90% ( P < .001), and planning target volume ≥2cc ( P = .007) were associated with inferior LC. All factors other than dose were significant on multivariate analysis ( P ≤ .002). One-year and 2-year OS rates were 68.0% (95% CI: 61.5%-73.6%) and 31.2% (95% CI: 24.6%-37.9%), respectively. Age > 65 years ( P = .006), KPS <90% ( P = .005), and extracranial metastases ( P = .05) were associated with inferior OS.

CONCLUSION

SRS resulted in comparable LC with common primaries. Age and KPS were associated with both LC and OS with planning target volume and extracranial metastases correlating with LC and OS, respectively. These factors should be considered in GI cancer patient selection for SRS.

Stereotactic radiosurgery for patients with brain metastases from gastroesophageal cancers

BACKGROUND

The prognosis of patients with brain metastases from gastroesophageal (GE) cancers remains unclear despite recent advances in systemic therapies. The authors present a large single-institution experience in the use of stereotactic radiosurgery (SRS).

METHODS

A retrospective review of 71 GE cancer patients (64 male, 90.14%) who underwent Gamma Knife SRS was conducted. Overall, 243 brain metastases were treated and the median number of metastases per patient was 2 (range:1-21). The median age at SRS was 66 years (range: 26-85) and the median treatment day KPS was 80 (range: 50-100). The median cumulative tumor volume was 6.7 cc (range: 0.27-104.76) and the median single-session margin dose was 18 Gy (range: 12-20).

RESULTS

The median overall survival after SRS was 7 months (range: 1-64). At last follow up, 54 (76.06%) patients were deceased, 8 of whom (14.81%) expired secondary to their intracranial metastases. Four patients (5.63%) experienced local tumor progression at a median time of 8 months (range: 2-13) after SRS. Ten patients (14%) experienced new remote tumor development at a median time of 4 months (range: 0-14) after SRS. Whole-brain radiation therapy (2 patients, 20%) and repeat SRS (8 patients, 80%) were used for newly developed tumors. The incidence of transient adverse radiation effects was 8.45%.

CONCLUSIONS

In this study, the 12-month local tumor control rate was 90%. Incidences of adverse radiation effect rates were rare. The median overall survival of 7 months indicates the poor prognosis of patients with brain spread of their GE cancer.

Genomic alterations of cerebrospinal fluid cell-free DNA in leptomeningeal metastases of gastric cancer

BACKGROUND

Leptomeningeal metastases (LM) were rare in gastric cancer (GC), and GC patients with LM (GCLM) generally suffer from poor prognosis. Nevertheless, the clinical utility of cerebrospinal fluid (CSF) circulating tumor DNA (ctDNA) was underinvestigated in GCLM.

METHODS

We retrospectively studied 15 GCLM patients, and all patients had paired primary tumor tissue samples and post-LM CSF samples while 5 patients also had post-LM plasma samples. All samples were analyzed using next-generation sequencing (NGS), and the molecular and clinical features were correlated with clinical outcomes.

RESULTS

CSF had higher mutation allele frequency (P = 0.015), more somatic mutations (P = 0.032), and more copy-number variations (P < 0.001) than tumor or plasma samples. Multiple genetic alterations and aberrant signal pathways were enriched in post-LM CSF, including CCNE1 amplification and cell cycle-related genes, and CCNE1 amplification was significantly associated with patients' overall survival (P = 0.0062). More potential LM progression-related markers were detected in CSF samples than in tumor samples, including PREX2 mutation (P = 0.014), IGF1R mutation (P = 0.034), AR mutation (P = 0.038), SMARCB1 deletion (P < 0.001), SMAD4 deletion (P = 0.0034), and TGF-beta pathway aberration (P = 0.0038). Additionally, improvement in intracranial pressure (P < 0.001), improvement in CSF cytology (P = 0.0038), and relatively low levels of CSF ctDNA (P = 0.0098) were significantly associated with better PFS. Lastly, we reported a GCLM case whose CSF ctDNA dynamic changes were well correlated with his clinical assessment.

CONCLUSIONS

CSF ctDNA could more sensitively detect molecular markers and metastasis-related mechanisms than tumor tissues in GCLM patients, and our study sheds light on utilizing CSF ctDNA in prognostic estimation and clinical assessment in GCLM.

Erythroblastic oncogene B-2 status and intracranial metastatic disease in patients with gastrointestinal cancer: a systematic review

PURPOSE

The incidence of intracranial metastatic disease (IMD) in patients with gastrointestinal (GI) cancers is rising. Expression of the erythroblastic oncogene B-2 (ERBB2) is associated with an in increased risk of IMD in patients with breast cancer. The implications of ERBB2 expression for IMD risk in patients with GI cancers is less clear. The objective of this systematic review was to determine the incidence of IMD and OS in patients with ERBB2+ gastrointestinal cancers.

METHODS

A literature search of MEDLINE, EMBASE, CENTRAL, and grey literature sources was conducted from date of database inception to July 2021. Included studies reported outcomes on patients with IMD secondary to ERBB2 GI cancers.

RESULTS

Fourteen cohort studies met inclusion criteria, of which thirteen were retrospective. Eleven studies reported on gastric, esophageal, or gastroesophageal junction cancers. Three studies directly compared incidence of IMD based on ERBB2 status and among these, ERBB2+ patients had a higher incidence of IMD. One study indicated that ERBB2+ patients had significantly longer OS from the times of primary cancer (P = .015) and IMD diagnosis (P = .01), compared with patients with ERBB2- disease.

CONCLUSIONS

In this systematic review, patients with ERBB2+ GI cancer were more likely to develop IMD. Future study is required on the prognostic and predictive value of ERBB2 status in patients with GI cancers.

Brain metastasis from gastric adenocarcinoma: A large comprehensive population-based cohort study on risk factors and prognosis

Aims

Although brain metastasis from gastric adenocarcinoma (GaC) is rare, it may significantly affect survival and quality of life. The aim of this large, comprehensive, population-based cohort investigation was to investigate factors that were associated with brain metastasis from GaC and to explore the prognostic factors and time-dependent cumulative mortalities among cases with GaC and brain involvement.

Methods

Population-based information on cases with GaC diagnosed from 2010 to 2016 was obtained from a large-scale database. Factors that were associated with brain metastasis were investigated utilizing multivariable logistic regression. Time-dependent tumor-specific mortalities of cases with GaC and brain involvement were then computed utilizing the cumulative incidence functions (CIFs), and mortalities were compared between subgroups utilizing Gray's test. Factors that were associated with death were further evaluated utilizing multivariable Fine-Gray subdistribution hazard regression.

Results

Together, 28,736 eligible cases were included, which comprised 231 (1%) cases with brain metastasis and 10,801 (38%) with metastasis to other sites, encompassing a follow-up of 39,168 person-years. Brain metastasis occurred more often among younger patients (within overall cancers), in cases with stomach cardia tumors, within cases with signet-ring cell carcinoma (within overall cancers), and within cases with positive lymph nodes (within overall tumors); it was less often detected among black people. Brain involvement was associated with more lung and bone metastases. The median survival time of cases having brain metastasis was only 3 months; the 6- and 12-month tumor-specific cumulative mortalities were 57% and 71%, respectively. Among cases with GaC and brain metastasis, those with gastric cardia cancers (when receiving radiotherapy), those undergoing resection, and those receiving chemotherapy had lower mortality risks, while younger patients (when receiving chemotherapy or radiotherapy) and people with positive lymph nodes (when receiving radiotherapy) had higher death hazards.

Conclusion

Among patients with GaC, brain metastasis was correlated with several clinical and pathological variables, including ethnicity, age, cancer histology, location, lymph node involvement, and metastases to other sites. Cases having brain metastasis had poor survival that was correlated with age, cancer location, lymph node metastasis, and management. These findings offer vital clues for individualized patient care and future mechanistic explorations.

Brain Metastasis from Pancreatic Cancer: Our Experience and Systematic Review

OBJECTIVE

To systematically review existing literature on the neurosurgical management and outcomes of brain metastasis from pancreatic cancer in comparison with our institutional experience of this patient cohort.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic literature review was performed using PubMed, Ovid Embase, Scopus, and Web of Science databases from date of database inception to March 2022. Studies were selected based on predetermined inclusion and exclusion criteria. Simultaneously, a retrospective analysis was conducted of patients who underwent neurosurgical evaluation and treatment for intracranial metastatic lesions from pancreatic origin at a single institution.

RESULTS

The original literature search yielded 292 articles, of which 17 studies comprising 23 patients with brain metastases of pancreatic origin were ultimately selected. Median overall survival from primary diagnosis of pancreatic cancer was 22 months (interquartile range: 3-84) and 3 months (interquartile range: 1-36) after diagnosis of brain metastasis. In our institutional cohort, 4 patients were identified with a median overall survival of 30.5 months (interquartile range: 2-108). Our institutional cohort experienced a prolonged median overall survival (3 months vs. 30.5 months, P = 0.03) compared with the literature.

CONCLUSIONS

Brain metastasis from pancreatic cancer is rare and associated with a fatal outcome. However, based on the data presented in this review, patient-specific and treatment-related factors could signal better prognosis. Further studies are needed to elucidate multimodal therapy and survival to suggest a more personalized decision-making process.

Case Report: Immune Checkpoint Inhibitors Successfully Controlled Asymptomatic Brain Metastasis in Esophageal Squamous Cell Carcinoma

Background

Brain metastases are the most common cause of intracranial malignancy, often resulting in significant morbidity and mortality. Brain metastases from esophageal squamous cell carcinoma (ESCC) are relatively rare, with a rate of generally less than 2%.

Case Report

In this article, we report a rare case of ESCC with asymptomatic brain metastasis. The combined positive score (CPS) of programmed cell death-ligand 1 (PD-L1) from the primary tumor was 2 by DAKO 22C3 and 3 by VENTANA SP263. The proportion of tumor infiltrating lymphocytes (TILs) was 1%. After receiving 15 cycles of immune checkpoint inhibitors (ICIs), the patient's brain metastatic lesion had disappeared and was replaced by a local necrotic area. He retains good cognitive function with a stable disease at the primary site.

Conclusions

This is the first to be reported in an ESCC patient whose brain metastatic lesion had a complete response to ICIs, which may provide supporting data for using ICIs as an option of treatment for ESCC patients with brain metastases.

Patients with brain metastases from gastric cancer

INTRODUCTION

The aim of this study was to retrospectively evaluate the treatment strategies and possible prognostic factors in patients with brain metastases from gastric cancers.

METHODS

We retrospectively reviewed 24 patients with brain metastases from gastric cancer who were treated at our center between January 2014 and March 2020. Clinicopathological characteristics and clinical outcomes were analyzed.

RESULTS

The median follow-up time was six months (range, 1-40). The median survival time after diagnosis of brain metastases was six months (95% confidence interval: 1.33-10.66). The one- and two-year survival rates were 30.7% and 5.1%, respectively. On univariate analyses, absence of extracranial metastases was significantly associated with better overall survival (OS) but not intracranial progression-free survival (iPFS), while Eastern Cooperative Oncology Group performance status (ECOG PS), whole brain radiotherapy (WBRT) and systemic treatments were significantly associated with better iPFS and OS. Multivariate analysis showed that ECOG PS, extracranial disease and systemic treatments were independent prognostic factors, while only systemic treatment influenced the iPFS. Two patients achieved partial response, 12 patients had progressive disease, and 10 patients remained stable. Local tumor control in our series was achieved in 50%. One patient, who received a combination of camrelizumab and apatinib therapy following whole brain radiotherapy, achieved an obvious partial response.

CONCLUSIONS

ECOG PS, extracranial disease and systemic treatments were independent prognostic factors for gastric cancer patients with brain metastases. The present best treatment for this group of patients was individual comprehensive therapy according to the different situation of each patient.

Treatment of brain metastases from gastrointestinal primaries: Comparing whole-brain radiotherapy and stereotactic radiosurgery in terms of survival

Objective:

The objective of the study was to analyze the clinical features and prognostic factors for survival in patients with brain metastasis (BM) from gastrointestinal primaries treated with whole-brain radiotherapy (WBRT) or stereotactic radiosurgery (SRS).

Methods:

We retrospectively investigated patients with BMs resulting from gastrointestinal primaries who underwent WBRT or SRS. The effects of treatment modalities on overall survival (OS) were calculated by the Kaplan–Meier method.

Results:

WBRT and SRS were applied to 24 and 17 patients, respectively. In the WBRT group, radiotherapy was delivered at 20–30 Gy in 5–10 fractions (fx). In the SRS group, a median dose of 22 Gy (range: 18–27 Gy) was applied in 1–3 fx. At BM diagnosis, all patients had synchronous extracranial metastases which were mostly detected in the lung and liver. Median OS values were 9 months and 4 months in the SRS and WBRT groups, respectively (p=0.005). Karnofsky performance status (KPS) score (≥70 vs. <70), diagnosis-specific graded prognostic index, gastrointestinal (GI) graded prognostic index, cumulative intracranial tumor volume (CITV), controlled systemic disease, and treatment modality (WBRT vs. SBRT) were found to be related with OS.

Conclusion:

In patients with GI cancer-related BMs, SRS should be preferred in those with longer OS expectancy who have controlled extracranial disease, good KPS and CITV values of <10 cm³.

Could intracranial tumor volume predict prognosis of patients with brain metastases from esophageal carcinoma?

PURPOSE

A previous study demonstrated that intracranial tumor volume had some correlation with gastrointestinal cancer patients' outcome. The aim of this study was to analyze patients with esophageal carcinoma (EC) and brain metastases to investigate if intracranial tumor volume would be a predictor of these patients' survival.

METHODS

A total of 52 patients with brain metastases from esophageal squamous cell carcinoma or esophageal adenocarcinoma were retrospectively reviewed. Patients without images of brain metastases in the hospital information system were eliminated.

RESULTS

The median follow-up time duration was 8.4 months (interquartile range 4.0-15.2). The median overall survival (OS) from time of brain metastases diagnosis was 8.0 months for all cases. Median OS of patients with small and large cumulative intracranial tumor volume (CITV) (<6.65 cm³ , ≥6.65 cm³ ) was 11.23 and 7.4 months, respectively. Median OS of patients with large and small largest intracranial tumor volume (LITV) (≥7.75 cm³ , <7.75 cm³ ) was 6.4 and 10.6 months, respectively. Univariate analysis demonstrated that CITV (hazard ratio [HR] 1.255, 95% confidence interval [CI] 0.673-2.342, p = 0.475) or LITV (HR 1.037, 95% CI 0.570-1.887, p = 0.904) was not significantly associated with improved OS. Multivariate analysis demonstrated that CITV and LITV were not significantly associated with improved OS.

CONCLUSION

EC patients with small intracranial tumor volume may have longer OS than those with large intracranial tumor volume, but this difference did not reach statistical difference. Future studies with a larger sample size may validate the correlation of intracranial tumor volume and patient survival.

Incidence and survival outcomes of secondary liver cancer: a Surveillance Epidemiology and End Results database analysis

Background

The global incidence and mortality rates of liver cancer, which is the second leading cause of cancer-related deaths worldwide, are increasing. However, information on its epidemiology and clinical prognosis is limited. This study aimed to characterize the epidemiology and prognostic factors of secondary liver cancer to aid in the pretreatment evaluation of the disease.

Methods

Patients diagnosed with secondary liver cancer between 2010 and 2014 in the Surveillance, Epidemiology, and End Results (SEER) database were retrospectively included. Kaplan-Meier analysis and Multivariate Cox regression analysis were performed to screen for significant factors associated with secondary liver cancer.

Results

A total of 85,738 secondary liver cancer patients were identified; in this population, the first primary site was the lung (25.9%), followed by the colorectum, pancreas, stomach, breast, and cecum. Patients with primary tumors of the colorectum, cecum and breast had longer median survival time. Advanced age, male gender, black race, poor differentiation or lack of differentiation, regional lymph node metastases, and presence of distant metastasis were associated with poor prognosis.

Conclusions

In this study, novel findings on the role of the primary site and synchronous distant metastasis to specific organs in patients with secondary liver cancer were described. These findings have significant implications in clinical diagnosis and treatment, and provide a better understanding of secondary liver cancer in the general population.

Structural and functional brain alterations associated with cancer-associated cognitive decline in gastric cancer patients: A preliminary longitudinal neuroimaging study

OBJECTIVE

Despite the clinical significance of cancer-associated cognitive decline (CACD), no longitudinal study has evaluated CACD in gastric cancer patients. This preliminary study explored structural and functional neural changes of CACD in gastric cancer patients focusing on the effects of chemotherapy.

METHODS

13 gastric cancer patients who received adjuvant chemotherapy (CTx+ group), 9 gastric cancer patients who did not receive adjuvant chemotherapy (CTx- group), and 10 healthy controls (HCs) were enrolled in this study. We performed self-report questionnaires, neurocognitive tests, voxel-based morphometry (VBM), and resting-state functional magnetic resonance imaging (rsfMRI) analyses before and 3 months after chemotherapy.

RESULTS

Compared to the CTx- group, the CTx+ group exhibited statistically significant decrease in attention and executive function over time and dysfunction in delayed recognition performance. The results of the rsfMRI analysis showed a significant group-by-time interaction in the left hippocampus-anterior thalamus. However, no significant structural change was observed in the VBM analysis.

CONCLUSION

To the best of our knowledge, this is the first longitudinal neuroimaging study on CACD in gastric cancer patients. Based on the results of our preliminary study, we suggest that the neuropathological processes and clinical presentation of CACD in gastric cancer patients is similar to those of patients associated with age-related neurodegenerative disorders.

Incidence and predictors of brain metastasis in colorectal cancer patients

PURPOSE

Brain metastasis (BM) in colorectal cancer patients is rare and is associated with dismal outcomes. Our study aims to evaluate the incidence and predictors of BM in patients with colorectal cancer.

METHODS

We performed a retrospective analysis (2010-2017) of patients with a primary diagnosis of colorectal cancer (CRC). Patients were stratified into two groups (BM vs. No-BM). Outcome measures were the incidence and predictors of BM. Multivariate logistic regression analysis was performed.

RESULTS

A total of 230,806 patients were analyzed. A total of 0.30% (n = 691) of the patients were found to have BM. On multivariate logistics regression, bone (OR: 5.39 [3.36-8.65], p < 0.001), lung (OR: 3.75 [2.67-5.28], < 0.001), and distant node metastasis (OR: 32.75 [20.47-52.41], p < 0.001) were independent predictors of BM.

CONCLUSION

Our study supports the low incidence of brain metastasis in patients with colorectal cancer. A unique set of characteristics is identified to confer an increased risk of brain metastases.

Monoamine Oxidase (MAO) as a Potential Target for Anticancer Drug Design and Development

Monoamine oxidases (MAOs) are oxidative enzymes that catalyze the conversion of biogenic amines into their corresponding aldehydes and ketones through oxidative deamination. Owing to the crucial role of MAOs in maintaining functional levels of neurotransmitters, the implications of its distorted activity have been associated with numerous neurological diseases. Recently, an unanticipated role of MAOs in tumor progression and metastasis has been reported. The chemical inhibition of MAOs might be a valuable therapeutic approach for cancer treatment. In this review, we reported computational approaches exploited in the design and development of selective MAO inhibitors accompanied by their biological activities. Additionally, we generated a pharmacophore model for MAO-A active inhibitors to identify the structural motifs to invoke an activity.

Clinicopathological characteristics and prognosis of brain metastases in elderly patients with esophageal carcinoma

BACKGROUND

Brain metastases (BM) from esophageal carcinoma (EC) is clinically rare and has not yet been reported in elderly patients. This study aimed to investigate the clinicopathological characteristics, outcomes and prognostic factors of BM in elderly patients with EC, in order to provide guidance for clinical practice.

METHODS

A total of 20 EC patients older than 65 years who were diagnosed with BM were identified from the fourth Hospital of Hebei Medical University between January 1, 2009 and December 31, 2018. Survival was evaluated by the Kaplan-Meier method and Cox proportional hazards models.

RESULTS

The median time from diagnosis of EC to BM was 11.8 months (0-249.2 months). The median overall survival (OS) was 4.8 months (1.13-23.3 months), with 20% of patients achieving the 1-year survival rate. Patients with KPS score of ≥70 had a significantly better OS than those with KPS score<70 (8.4 vs. 3.9 months, p = 0.033). Compared to patients without brain radiotherapy, patients with brain radiotherapy showed better outcomes in both median OS (8.4 vs. 2.9 months) and 1-year survival rate (23.1% vs. 14.3%, p = 0.043). The median OS of patients with radiotherapy combined with chemotherapy and/or targeted therapy and radiotherapy alone was 9.7 months (3.4-23.3 months) and 7.2 months (1.7-18.4 months), respectively, with no significant difference between the two groups (p = 0.215).

CONCLUSIONS

Brain radiotherapy provided clinically meaningful survival benefit for elderly patients with BM from EC. Thus, active treatments for those patients might be required.

Factors Prognostic for Brain Metastases from Colorectal Cancer: A Single-Center Experience in China

Purpose

This study aimed to analyze clinicopathological, survival, prognostic factors, as well as the timing of brain metastases (BM) in colorectal cancer (CRC) using data from a Chinese center.

Patients and Methods

Data of 65 consecutive CRC patients with BM were collected from a single institution in China. The time from primary tumor surgery to the occurrence of BM was calculated. Kaplan-Meier analysis was used to evaluate cumulative survival of patients. Factors associated with prognosis of overall survival (OS) were explored using Cox's proportional hazard regression models.

Results

The median time interval from CRC surgery to the diagnosis of BM was 24 months. After diagnosis of BM, median OS values for patients were 11 months. Extracranial metastases occurred in 45 cases (69.2%) when BM was diagnosed, and 58.5% of these patients with lung metastases Time of BMs (P=0.018), presence of extracranial metastases (P=0.033), treatment (P=0.003), CA199 (P=0.034), CA125 (P<0.001), CA242 (P=0.018), and CA211 (P=0.012) were associated with OS of patients through univariate analysis. Multivariate analysis using a Cox regression model showed that only treatment was an independent predictor for OS (conservative treatment; HR=1.861, 95% CI=1.077-3.441; P=0.048).

Conclusion

Surgical treatment of metastatic lesions may be an alternative choice for CRC patients with BM. Identifying the timing of brain metastases can help to detect this disease early, leading to a better survival outcome.

Surgery for metachronous oligometastatic esophageal cancer: Is there enough evidence?

Esophageal cancer is the sixth most common cause of cancer-related mortality worldwide. Despite advances in diagnostic modalities and treatment options, five-year survival rates are below 20%. Esophagectomy with extended lymph node dissection is the mainstay of treatment. More than 50% of patients experience recurrence within 1-3 years postoperatively. Recurrent disease may present locoregionally at the site of anastomosis or as recurrence through lymphatic spread in lymph node basins, as hematogenic metastasis, or as a combination of these. The standard treatment of recurrence is currently predicated on systemic chemotherapy and/or radiotherapy. Recent evidence suggests that surgical treatment of metachronous oligometastatic disease may be prognostically advantageous over medical management alone. Given the considerably low response rates to chemoradiotherapy, many institutions have adopted surgical treatment strategies for oligo-recurrent disease on a case-by-case basis. The aim of this article is to review the current evidence on the role of surgical treatment for metachronous oligometastases from esophageal cancer.

Current status of gastrointestinal tract cancer brain metastasis and the use of blood-based cancer biomarker biopsy

Brain metastasis (BM) frequently occurs in patients with cutaneous melanoma, lung, and breast cancer; although, BM rarely arises from cancers of the gastrointestinal tract (GIT). The reported incidence of GIT cancer BM is less than 4%. In the last few years, effective systemic therapy has prolonged the survival of GIT patients and consequently, the incidence of developing BM is rising. Therefore, the epidemiology and biology of BM arising from GIT cancer requires a more comprehensive understanding. In spite of the development of new therapeutic agents for patients with metastatic GIT cancers, survival for patients with BM still remains poor, with a median survival after diagnosis of less than 4 months. Limited evidence suggests that early detection of isolated intra-cranial lesions will enable surgical resection plus systemic and/or radiation therapy, which may lead to an increase in overall survival. Novel diagnostic methods such as blood-based biomarker biopsies may play a crucial role in the early detection of BM. Circulating tumor cells and circulating cell-free nucleic acids are known to serve as blood biomarkers for early detection and treatment response monitoring of multiple cancers. Blood biopsy may improve early diagnosis and treatment monitoring of GIT cancers BM, thus prolonging patients' survivals.

Brain Metastases from Esophageal Squamous Cell Carcinoma: Clinical Characteristics and Prognosis

PURPOSE

Due to the low incidence of intracranial disease among patients with esophageal cancer (EC), optimal management for these patients has not been established. The aim of this real-world study is to describe the clinical characteristics, treatment approaches, and outcomes for esophageal squamous cell carcinoma (ESCC) patients with brain metastases in order to provide a reference for treatment and associated outcomes of these patients.

METHODS

Patients with ESCC treated at the Fourth Hospital of Hebei Medical University between January 1, 2009 and May 31,2020 were identified in an institutional tumor registry. Patients with brain metastases were included for further analysis and categorized by treatment received. Survival was evaluated by the Kaplan-Meier method and Cox proportional hazards models.

RESULTS

Among 19,225 patients with ESCC, 66 (0.34%) were diagnosed with brain metastases. Five patients were treated with surgery, 40 patients were treated with radiotherapy, 10 with systemic therapy alone, and 15 with supportive care alone. The median follow-up time was 7.3 months (95% CI 7.4-11.4). At last follow-up, 59 patients are deceased and 7 patients are alive. Median overall survival (OS) from time of brain metastases diagnosis was 7.6 months (95% CI 5.3-9.9) for all cases. For patients who received locoregional treatment, median OS was 10.9 months (95% CI 7.4-14.3), and survival rates at 6 and 12 months were 75.6% and 37.2%, respectively. For patients without locoregional treatment, median OS was 3.0 months (95% CI 2.5-3.5), and survival rates at 6 and 12 months were 32% and 24%, respectively. OS was significantly improved for patients who received locoregional treatment compared to those treated with systematic treatment alone or supportive care (HR: 2.761, 95% CI 1.509-5.053, P=0.001). The median OS of patients with diagnosis-specific graded prognostic assessment (DS-GPA) score 0-2 was 6.4 months, compared to median OS of 12.3 months for patients with DS-GPA >2 (HR: 0.507, 95% CI 0.283-0.911).

CONCLUSION

Brain metastases are rare in patients with ESCC. DS-GPA score maybe a useful prognostic tool for ESCC patients with brain metastases. Receipt of locoregional treatment including brain surgery and radiotherapy was associated with improved survival.

Surgery for metachronous oligometastatic esophageal cancer: Is there enough evidence?

Esophageal cancer is the sixth most common cause of cancer-related mortality worldwide. Despite advances in diagnostic modalities and treatment options, five-year survival rates are below 20%. Esophagectomy with extended lymph node dissection is the mainstay of treatment. More than 50% of patients experience recurrence within 1-3 years postoperatively. Recurrent disease may present locoregionally at the site of anastomosis or as recurrence through lymphatic spread in lymph node basins, as hematogenic metastasis, or as a combination of these. The standard treatment of recurrence is currently predicated on systemic chemotherapy and/or radiotherapy. Recent evidence suggests that surgical treatment of metachronous oligometastatic disease may be prognostically advantageous over medical management alone. Given the considerably low response rates to chemoradiotherapy, many institutions have adopted surgical treatment strategies for oligo-recurrent disease on a case-by-case basis. The aim of this article is to review the current evidence on the role of surgical treatment for metachronous oligometastases from esophageal cancer.

Bilateral Hearing Loss Due to Metastatic Gastric Signet Cell Adenocarcinoma Involving the Internal Auditory Canal and Cerebellopontine Angle

Intracranial metastases of stomach cancers are very rare and are associated with a poor prognosis. Of those, metastases of gastric cancers in the internal auditory canal and cerebellopontine angle represent an extremely rare subgroup. Such metastatic lesions may be indistinguishable from vestibular schwannomas in imaging studies and clinical presentation. In this report, we describe a case of gastric signet cell adenocarcinoma metastasizing to the internal auditory canal and cerebellopontine angle bilaterally and causing bilateral hearing loss, including a unilateral sudden deafness. Due to the co-detection of multiple other intracranial masses in the magnetic resonance imaging scan, the suspected diagnosis of leptomeningeal metastatic disease was clear, and the patient was referred to palliative whole brain radiotherapy. The case further highlights the importance of prompt diagnosis and treatment of metastatic cerebellopontine angle lesions to prevent permanent neurological sequelae. Metastatic tumors should therefore be considered in the differential diagnosis of cerebellopontine angle lesions, especially in patients with a known history of malignant disease.

Durable 5-year local control for resected brain metastases with early adjuvant SRS: the effect of timing on intended-field control

Background

Adjuvant stereotactic radiosurgery (SRS) improves the local control of resected brain metastases (BrM). However, the dependency of long-term outcomes on SRS timing relative to surgery remains unclear.

Methods

Retrospective analysis of patients treated with metastasectomy-plus-adjuvant SRS at Memorial Sloan Kettering Cancer Center (MSK) between 2013 and 2016 was conducted. Kaplan-Meier methodology was used to describe overall survival (OS) and cumulative incidence rates were estimated by type of recurrence, accounting for death as a competing event. Recursive partitioning analysis (RPA) and competing risks regression modeling assessed prognostic variables and associated events of interest.

Results

Two hundred and eighty-two patients with BrM had a median OS of 1.5 years (95% CI: 1.2-2.1) from adjuvant SRS with median follow-up of 49.8 months for survivors. Local surgical recurrence, other simultaneously SRS-irradiated site recurrence, and distant central nervous system (CNS) progression rates were 14.3% (95% CI: 10.1-18.5), 4.9% (95% CI: 2.3-7.5), and 47.5% (95% CI: 41.4-53.6) at 5 years, respectively. Median time-to-adjuvant SRS (TT-SRS) was 34 days (IQR: 27-39). TT-SRS was significantly associated with surgical site recurrence rate (P = 0.0008). SRS delivered within 1 month resulted in surgical site recurrence rate of 6.1% (95% CI: 1.3-10.9) at 1-year, compared to 9.2% (95% CI: 4.9-13.6) if delivered between 1 and 2 months, or 27.3% (95% CI: 0.0-55.5) if delivered >2 months after surgery. OS was significantly lower for patients with TT-SRS >~2 months. Postoperative length of stay, discharge to a rehabilitation facility, urgent care visits, and/or disease recurrence between surgery and adjuvant SRS associated with increased TT-SRS.

Conclusions

Adjuvant SRS provides durable local control. However, delays in initiation of postoperative SRS can decrease its efficacy.

Long-term survival after surgical resection of metachronous lung, brain and thyroid gland metastases from rectal cancer: A case report

•

Brain and thyroid metastasis of rectal cancer are uncommon, and prognosis are poor.

•

Lung, brain and thyroid metastasis of rectal cancer was resected metachronous.

•

This case survived 19 years after the initial rectal surgery.

•

Patients whose metastases were resected completely may get a prolonged survival.

Introduction and importance

Brain and thyroid metastasis from rectal cancer are uncommon, and the prognosis is poor. We report a patient with rectal cancer who developed metachronous lung, brain and thyroid metastases. Each metastatic lesion was curatively resected resulting in prolonged survival.

Case presentation

A 60-year-old male underwent rectal cancer resection, and the pathological diagnosis was tubular adenocarcinoma, pT2,pN1a,M0, pStageⅢa. Ten years after rectal resection, a solitary tumor in the left lung was detected. The tumor was resected thoracoscopically and the pathological diagnosis was metastatic tumor. Three years after the pulmonary resection, a solitary brain tumor was detected. The tumor was removed surgically, and the pathology was metastatic tumor. Two years after brain resection, a thyroid mass was detected. A partial thyroidectomy was performed and the pathology with immunohistochemical staining confirmed the thyroid lesion as a metastasis from the previous rectal cancer. Four years after thyroid resection (19 years after the initial rectal resection), he died from multiple lung and bone metastases.

Clinical discussion

Colorectal metastases to the brain and thyroid gland are uncommon and are usually found with other distant metastases. Overall survival has been reported to be extremely poor. In this patient, lung, brain, and thyroid metastases were solitary and metachronous, and each lesion was curatively resected. Surgical treatment might contribute to prolonged survival.

Conclusion

The treatment strategy of each patient should be individualized and depends on the timing of metastasis development. Selected patients with complete resection of metachronous metastases may have prolonged survival.

Personalized Antibodies for Gastroesophageal Adenocarcinoma (PANGEA): A Phase II Study Evaluating an Individualized Treatment Strategy for Metastatic Disease

The one-year and median overall survival (mOS) rates of advanced gastroesophageal adenocarcinomas (GEA) are ∼50% and <12 months, respectively. Baseline spatial and temporal molecular heterogeneity of targetable alterations may be a cause of failure of targeted/immunooncologic therapies. This heterogeneity, coupled with infrequent incidence of some biomarkers, has resulted in stalled therapeutic progress. We hypothesized that a personalized treatment strategy, applied at first diagnosis then serially over up to three treatment lines using monoclonal antibodies combined with optimally sequenced chemotherapy, could contend with these hurdles. This was tested using a novel clinical expansion-platform type II design with a survival primary endpoint. Of 68 patients by intention-to-treat, the one-year survival rate was 66% and mOS was 15.7 months, meeting the primary efficacy endpoint (one-sided P = 0.0024). First-line response rate (74%), disease control rate (99%), and median progression-free survival (8.2 months) were superior to historical controls. The PANGEA strategy led to improved outcomes warranting a larger randomized study. SIGNIFICANCE: This study highlights excellent outcomes achieved by individually optimizing chemotherapy, biomarker profiling, and matching of targeted therapies at baseline and over time for GEA. Testing a predefined treatment strategy resulted in improved outcomes versus historical controls. Therapeutic resistance observed in correlative analyses suggests that dual targeted inhibition may be beneficial.This article is highlighted in the In This Issue feature, p. 211.

Surgical management of oligometastatic disease in gastric cancer

A distinctive subset of metastatic gastric cancer (MGC) is oligometastatic disease (OMD), which is characterized by metastatic lesions limited in number and location. Although growing evidence mainly based on retrospective analysis or single center case series has shown favorable prognosis in the management of OMD in gastric cancer with aggressive local treatment, no existing guidelines explicitely address the definition of OMD and there are still controversial opinions on how to proceed in a new era with more effective systemic therapy selection. In this review, we present the current advances and evidence as well as controversial on the management of OMD in MGC, including the definition, diagnosis, local aggressive treatments especially surgery, prognostic factors, current ongoing randomized clinical studied as well as challenges facing the field.

Anterior Clinoid Metastasis as First Presentation of a Signet Ring Cell Carcinoma: An Intriguing Diagnosis

Background  We report an extremely unusual case of anterior clinoid process (ACP) metastasis as the first presentation of a signet ring cell carcinoma.

Case Description  A 54-year-old female patient presented with right-sided visual disturbances due to optic nerve compression from a computed tomography (CT)-identified right anterior clinoid bone lesion. Contrast-enhanced magnetic resonance imaging showed an extra-axial, well-bordered enhancing mass extending from the right ACP toward the inner lumen of the optic canal. Pterional approach was adopted to remove the lesion and decompress the optic canal. Histological examination demonstrated a metastasis from a signet ring cell carcinoma. Postoperative CT showed near-total resection of the tumor and decompression of the optic canal. Visual defect remained unchanged.

Conclusion  Metastasis should be considered in the differential diagnosis of the ACP lesions. The early suspicion and identification of this extremely rare pathological entity can be helpful for the prompt management of patients, especially in the absence of any other signs of oncological diseases.

Colorectal Cancer Metastases to Brain or Bone and the Relationship to Primary Tumor Location: a Population-Based Study

BACKGROUND

The association of primary tumor location with incidence and prognosis of brain or bone metastasis in metastatic colorectal cancer (mCRC) patients remains unclear. We dissect this association across a large population.

METHODS

A total of 202,401 CRC patients from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2015 were included. For brain metastasis, 9478 cases without brain metastasis information were excluded, leaving 192,923 CRC for incidence analysis and multivariable logistic/Cox regression analyses. Similarly, 193,013 CRC were eligible for bone metastasis analyses.

RESULTS

The incidence of brain or bone metastasis at initial diagnosis was 1.38% and 6.12% in mCRC cohort, respectively. Median survival of CRC patients with brain or bone metastasis was 4 and 5 months, respectively. Primary tumor location is not associated with the incidence of brain metastasis but with bone metastasis. For bone metastasis, right-sided colon cancer (RCC) patients exhibited the lowest incidence, whereas rectal cancer (RC) patients had the highest. For both brain and bone metastases, RCC patients always had the shortest median survival, whereas RC patients had the longest. The common risk factors for brain or bone metastasis were grade III and multi-extracerebral or ectosteal metastases. The favorable prognostic factors for brain or bone metastasis were being female, married, insured, and RC. RCC is an unfavorable prognostic factor.

CONCLUSIONS

Primary tumor location impacts incidence proportions of bone metastasis and survival of both brain and bone mCRC patients. Primary tumor location should be taken into consideration in clinical practice and prognostic assessment.

Which is the optimal management for locally advanced gastric cancer patients with TRG 0 and 1 after R0 resection?

Background

Neoadjuvant chemotherapy (NAC) followed by surgery currently offers promise as a strategy for patients with locally advanced gastric cancer (GC). However, there is limited evidence to guide treatment for TRG 0 and 1 patients with locally advanced GC after R0 resection. This study set out to explore the optimal management for TRG 0 and 1 patients with locally advanced GC after R0 resection.

Methods

The retrospective data of 154 TRG 0 and 1 patients with locally advanced GC following R0 resection who were treated between January 2012 and December 2018 were collected and analyzed. The Kaplan-Meier method was used to estimate the survival rate. Multivariate analysis was performed using the Cox proportional hazards model.

Results

The median follow-up was 34.1 (range, 6.6–90.9) months. Six patients (3.9%) were lost during follow-up. Of the 27 patients who experienced relapse, 12 died, including 2 patients who died of non-neoplastic causes. The 5-year recurrence-free survival (RFS) and 5-year overall survival (OS) were 71.6% (95% CI: 68.5–79.6) and 82.9% (95% CI: 76.9–86.1) for the whole cohort, respectively. Univariate analysis revealed that patients with carcinoembryonic antigen (CEA) <5.0 ng/ml after NAC (77.7% vs. 20.1%, P<0.001), distal gastrectomy (91.7% vs. 67.5%, P=0.046) had higher 5-year RFS. Meanwhile, combined resection (55.6% vs. 73.1%, P=0.042), major complications (42.7% vs. 80.50%, P<0.001), and lymph node metastasis (ypN+) (52.0% vs. 83.7%, P<0.001) had lower 5-year RFS. The multivariate analysis showed that CEA level after NAC (HR =2.876, 95% CI: 1.051–7.872, P=0.040), major complications (HR =2.432, 95% CI: 1.062–5.567, P=0.035), and lymph node metastasis (ypN+) (HR =3.183, 95% CI: 1.242–8.161, P=0.016) were independent prognostic factors.

Conclusions

TRG 0 and 1 patients with local GC after R0 resection following NAC had a good prognosis, especially patients with CEA <5.0 ng/mL after NAC, and those without major complications or lymph node metastasis. Monotherapy or no chemotherapy may offer options for treating TRG 0 and 1 patients without adverse prognostic factors.

Brain metastases from esophageal cancer: A case report

INTRODUCTION

At present, there is no uniform consensus on the treatment of brain metastases from esophageal cancer. The studies on the treatment of brain metastases from esophageal cancer by radiotherapy combined with temozolomide (TMZ) are even rarer.

PATIENT CONCERNS

A 69-year-old woman was admitted to our hospital for brain metastases from esophageal cancer after thoracic irradiation.

DIAGNOSES

Magnetic resonance imaging of the head showed a round, heterogeneous metastatic tumor in the left parietal lobe. Brain magnetic resonance imaging showed edema around brain metastasesInterventions: After radiotherapy plus TMZ in this patient's head, the brain metastatic tumor was significantly decreased.

OUTCOMES

At the end of radiotherapy, and 1 and 2 months after the end of radiotherapy, the metastatic tumor continued to shrink, and no obvious side effects were observed.

LESSONS

This study suggests that radiotherapy plus TMZ might be a feasible option for brain metastases from esophageal cancer.

Prognostic factors for survival in colorectal cancer patients with brain metastases undergoing whole brain radiotherapy: multicenter retrospective study

Whole brain radiotherapy (WBRT) is a mainstay of the treatment for brain metastases (BM). We evaluated prognostic factors in colorectal cancer (CRC) patients undergoing WBRT for BM. The medical records of 106 CRC patients undergoing WBRT for BM between 2000 and 2014 at three institutions were reviewed. Patient and tumor factors were analyzed to identify the prognostic factors for overall survival (OS) calculated from the date of BM diagnosis to the date of death or last follow-up. Surgical resection of BM was performed in six patients. The dose of WBRT was 30 Gy, and boost radiotherapy or stereotactic radiosurgery (8–23 Gy) was given to 15 patients. Systemic therapy for BM was administered in one patient before WBRT and 26 patients after WBRT. The median follow-up time was 3.9 months (range, 0.4–114.1 months). The median OS time was 3.9 months, and the 1-year OS rate was 18.2%. Older age (>65 years), multiple BM (≥3), elevated level of carcinoembryonic antigen (CEA, >5 ng/ml) at BM diagnosis, and extracranial metastases were adverse prognostic factors for OS. Patient with 0–1 factor showed better OS (at 1 year, 76.9%) than patients with 2 factors (16.7%) or 3–4 factors (4.2%; p < 0.001). In conclusion, we evaluated age, the number of BM, CEA level, and extracranial metastases as the prognostic factors for OS in CRC patients undergoing WBRT. Our result might be useful to develop prognostic models predicting survival for patients whom WBRT is intended for.

Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2019 for the treatment of colorectal cancer

The number of deaths from colorectal cancer in Japan continues to increase. Colorectal cancer deaths exceeded 50,000 in 2016. In the 2019 edition, revision of all aspects of treatments was performed, with corrections and additions made based on knowledge acquired since the 2016 version (drug therapy) and the 2014 version (other treatments). The Japanese Society for Cancer of the Colon and Rectum guidelines 2019 for the treatment of colorectal cancer (JSCCR guidelines 2019) have been prepared to show standard treatment strategies for colorectal cancer, to eliminate disparities among institutions in terms of treatment, to eliminate unnecessary treatment and insufficient treatment and to deepen mutual understanding between healthcare professionals and patients by making these guidelines available to the general public. These guidelines have been prepared by consensuses reached by the JSCCR Guideline Committee, based on a careful review of the evidence retrieved by literature searches and in view of the medical health insurance system and actual clinical practice settings in Japan. Therefore, these guidelines can be used as a tool for treating colorectal cancer in actual clinical practice settings. More specifically, they can be used as a guide to obtaining informed consent from patients and choosing the method of treatment for each patient. Controversial issues were selected as clinical questions, and recommendations were made. Each recommendation is accompanied by a classification of the evidence and a classification of recommendation categories based on the consensus reached by the Guideline Committee members. Here, we present the English version of the JSCCR guidelines 2019.

The Choice of Local Treatment Modalities for Patients with Brain Metastases from Digestive Cancers

Background

Brain metastases (BMs) from digestive cancers are rare; therefore, no optimal treatment modality has been defined.

Methods

We retrospectively reviewed the clinical data of 68257 patients with digestive cancers. Propensity score matching (PSM) was used to balance patient backgrounds between groups. Survival differences between different treatment modalities were compared. Univariate and multivariate Cox proportional hazards models were performed to identify prognostic factors on overall survival (OS).

Results

270 patients with BM entered the study. In the entire group, the median survival time after diagnosis of brain metastases was 10.25 months (95% CI: 8.41–12.09 months); local treatment could significantly prolong OS (respectively, P < 0.01; even after PSM, P < 0.01); combination treatment was more effective than single treatment modality (respectively, P < 0.01; even after PSM, P < 0.01). However, each combination modality was identically effective (P > 0.05). When patients were divided into three groups based on 1, 2-3, or more than 3 metastatic lesion(s), same results were identified between local treatment and without local treatment (1 lesion, P < 0.01; 2-3 lesions, P < 0.01; more than 3 lesions, P < 0.01, respectively) and combination and single treatment (P < 0.01, P=0.02, P=0.03, respectively). However, there was no difference between different combined treatments (P > 0.05). Multivariate analysis revealed that performance status (P < 0.01), presence of extracranial metastasis (P=0.04), number of BM (P < 0.01), and local treatment for BM (P < 0.01) were independent prognostic factors.

Conclusions

Regardless of the number of brain lesions, local treatment achieved higher overall survival times than no local treatment, and combination therapy could offer survival benefit to patients as compared with single therapy.