Successful treatment of brain metastases from ovarian cancer using gamma-knife radiosurgery

Central nervous system metastasis in gynecologic cancers: Seeking the prognostic factors

OBJECTIVE

Central nervous system (CNS) metastasis originating from gynecological cancer is a very rare and late manifestation of the disease. Therefore, there is still limited data on prognostic factors for survival. The objective of the present study is to identify prognostic factors for survival in patients with CNS metastasis originating from gynecological cancer.

STUDY DESIGN

The present retrospective study analyzed the patients with gynecological cancers who were treated due to CNS metastases between January 1999 and December 2019 at Istanbul University Hospital.

RESULTS

Forty-seven patients with CNS metastasis of gynecological origin were included in the study. The median age at the time of CNS metastasis was 59 (range 34-93). The median time from initial cancer diagnosis to CNS metastasis was 24.9 (range: 0-108.2) months. Most patients had epithelial ovarian cancer (EOC) (76.6%), followed by endometrial cancer (EC) (14.8%), cervical cancer (CC) (4.3%), and vulvar cancer (VC) (4.3%). By multivariate analysis, the presence of extracranial metastasis (HR: 5.10; 95% CI: 1.71-15.18), Eastern Cooperative Oncology Group (ECOG) performance status ≥3 (HR: 2.92; 95% CI: 1.36-6.26), palliative care only for the treatment of CNS metastasis (HR: 1.47; 95% CI: 0.58-4.11), and treatment-free interval (TFI) <6 months (HR: 2.74; 95% CI: 1.23-6.08) were independent factors that associated with worse survival.

CONCLUSION

Patients with CNS metastasis who have favorable prognostic factors are considered to be appropriate candidates for aggressive and long-term treatment strategies. Extracranial metastasis, ECOG performance status, treatment history of CNS metastasis, and TFI were determined as independent prognostic factors that improved survival. TFI might be taken into account as a prognostic factor for patients with CNS metastasis in gynecological cancer.

Gamma Knife radiosurgery for metastatic brain tumors from ovarian cancer: histopathological analysis of survival and local control. A Japanese multi-institutional cooperative and retrospective cohort study

OBJECTIVE

Brain metastasis is rare in ovarian cancer patients. The results of Gamma Knife radiosurgery (GKRS) for the treatment of patients with brain metastases from ovarian cancer were retrospectively analyzed to derive the efficacy and prognostic factors for survival and local tumor control. Further histopathological analysis was also performed.

METHODS

The authors retrospectively reviewed the medical records of 118 patients with 566 tumors who had undergone GKRS at the 10 GKRS institutions in Japan.

RESULTS

After the initial GKRS, the median overall survival time was 18.1 months. Multivariate analysis showed that uncontrolled primary cancer (p = 0.003) and multiple intracranial metastases (p = 0.034) were significant unfavorable factors. Ten patients died of uncontrolled brain metastases at a median of 17.1 months. The 6-, 12-, and 24-month neurological death rates were 3.2%, 4.6%, and 11.9%, respectively. The 6-, 12-, and 24-month neurological deterioration rates were 7.2%, 13.5%, and 31.4%, respectively. The 6-, 12-, and 24-month distant brain control failure rates were 20.6%, 40.2%, and 42.3%, respectively. Median tumor volume was 1.6 cm3 and marginal dose was 20 Gy. The 6-, 12-, and 24-month local tumor control rates were 97.6%, 95.2%, and 88.0%, respectively. Peritumoral edema (p = 0.043), more than 7-cm3 volume (p = 0.021), and prescription dose less than 18 Gy (p = 0.014) were factors that were significantly correlated in local tumor control failure. Eight patients had symptomatic radiation injury. The 6-, 12-, and 24-month GKRS-related complication rates were 3.3%, 7.8%, and 12.2%, respectively. Primary ovarian cancer was histopathologically diagnosed for 313 tumors in 69 patients. Serous adenocarcinoma was found in 37 patients and other types in 32 patients. Median survival times were 32.3 months for the serous type and 17.4 months for other types after initial GKRS. Patients with serous-type tumors survived significantly longer than patients with other types (p = 0.039). The 6-, 12-, and 24-month local tumor control rates were 100%, 98.8%, and 98.8%, respectively. Serous-type tumors were a significantly good prognosis factor for local tumor control after GKRS (p = 0.005).

CONCLUSIONS

This study established a relationship between the efficacy of GKRS treatment for brain metastases and the histological type of primary ovarian cancer. GKRS for ovarian cancer brain metastasis can provide satisfactory survival and local control, especially in cases of serous adenocarcinoma.

[Surgical management of brain metastases following female reproductive system cancers: analysis of 37 cases]

Background. Previously, treatment of women with brain metastases following reproductive system cancers was palliative and included whole brain radiotherapy. Currently, treatment approaches have changed and life expectancy has increased. Nevertheless, the role of surgical treatment in these patients is still discussed.

OBJECTIVE

To demonstrate an appropriateness and role of neurosurgical care in the complex management of women with brain metastases following reproductive system cancers.

MATERIAL AND METHODS

There were 78 women with brain metastases following reproductive system cancer. All patients were treated at the Blokhin National Cancer Medical Research Center for the period 2004-2019. We have also reviewed the literature data for the last 30 years.

Results and discussion. Resection of brain metastases in complex treatment of endometrial, ovarian and cervical cancer ensured favorable long-term survival in our material. Thus, mean life expectancy after resection of brain metastases was 16.3 months in patients with ovarian cancer, uterine cancer - 15.6 months, cervical cancer - 10.25 months. Obviously, surgery is not indicated in all cases. However, this approach improves local control and should be used in combination with other treatment methods for improvement of life expectancy and its quality in certain patients.

CONCLUSION

Selective surgical approach should be essential in the treatment of patients with brain metastases following reproductive system cancer. A multidisciplinary approach ensures the best treatment outcomes.

Surgical management of lung, liver and brain metastases from gynecological cancers: a literature review

Background

The management of patients with recurrent gynecological malignancy is complex, and often contentious. While historically, patients with metastases in the lungs, liver or brain have been treated with palliative intent, surgery is proving to have an increasing role in the management of such patients.

Methods

In this review article, the surgical management of lung, liver and brain metastases from gynecological cancers is examined. A search of the English language literature over the last 25 years was conducted using the Medline and PubMed databases.

Results

The results for management of metastases from the endometrium, ovary and cervix to the lung, brain and liver show that surprisingly good long-term survival results can be achieved for resection of metastases from all three organs. Patient selection is critical, and surgery is often used in conjunction with other treatment modalities.

Conclusions

From this review, it is apparent that surgery should play an increasing role in the management of patients with parenchymal metastases from gynecological cancers. The surgery should ideally be performed in high volume, tertiary centers where there is a committed multi-disciplinary team with the necessary infrastructure to achieve the best possible outcomes in terms of both survival and morbidity.

Brain metastases in women with epithelial ovarian cancer: multimodal treatment including surgery or gamma-knife radiation is associated with prolonged survival

OBJECTIVE

To explore the impact of treatment modality on survival in patients with brain metastases from epithelial ovarian cancer.

METHODS

We conducted a retrospective review of cases of ovarian cancer with brain metastases treated at institutions in three countries (Canada, China, and India) and conducted a search for studies regarding brain metastases in ovarian cancer reporting survival related to treatment modality. Survival was analyzed according to treatment regimens involving (1) some form of surgical excision or gamma-knife radiation with or without other modalities, (2) other modalities without surgery or gamma-knife radiation, or (3) palliation only.

RESULTS

Twelve patients (mean age 56 years) with detailed treatment/outcome data were included; five were from China, four from Canada, and three from India. Median time from diagnosis of ovarian cancer to brain metastasis was 19 months (range 10 to 37 months), and overall median survival time from diagnosis of ovarian cancer was 38 months (13 to 82 months). Median survival time from diagnosis of brain metastasis was 17 months (1 to 45 months). Among patients who had multimodal treatment including gamma-knife radiotherapy or surgical excision, the median survival time after the identification of brain metastasis was 25.6 months, compared with 6.0 months in patients whose treatment did not include this type of focused localized modality (P = 0.006). Analysis of 20 studies also indicated that use of gamma-knife radiotherapy and excisional surgery in multi-modal treatment resulted in improved median survival interval (25 months vs. 6.0 months, P < 0.001).

CONCLUSION

In the subset of patients with brain metastases from ovarian cancer, prolonged survival may result from use of multidisciplinary therapy, particularly if metastases are amenable to localized treatments such as gamma-knife radiotherapy and surgical excision.

Gamma knife surgery for brain metastases from ovarian cancer

Background

Brain metastases from ovarian cancer are rare, but their incidence is increasing. The purpose of this study was to investigate the characteristics of brain metastases from ovarian cancer, and to assess the efficacy of treatment with gamma knife surgery (GKS).

Methods

A retrospective review was performed of patients with brain metastases from ovarian cancer who were treated at the Tokyo Gamma Unit Center from 2006 to 2010.

Results

Sixteen patients were identified. Their median age at diagnosis of brain metastases was 56.5 years, the median interval from diagnosis of ovarian cancer to brain metastases was 27.5 months, and the median number of brain metastases was 2. The median Karnofsky Performance Score (KPS) at the first GKS was 80. The median survival following diagnosis of brain metastases was 12.5 months, and 6-month and 1-year survival rates were 75 % and 50 %, respectively. The tumor control rate was 86.4 %. The KPS (<80 vs ≥80) and total volume of brain metastases (<10 cm³ vs ≥10 cm³) were significantly associated with survival according to a univariate analysis (p = 0.004 and p = 0.02, respectively).

Conclusions

The results of this study suggest that GKS is an effective remedy and acceptable choice for the control of brain metastases from ovarian cancer.

Brain metastases from ovarian carcinoma

This paper will focus on knowledge related to brain metastases from ovarian carcinoma. So far, less than 600 cases were documented in the literature with an incidence among ovarian carcinoma patients ranging from 0.29% to 11.6%. The ovarian carcinoma was usually an advanced-stage epithelial serous carcinoma, and the median interval between diagnosis of ovarian carcinoma and brain metastases was 2 years. Most often, brain metastases, affected the cerebrum, were multiple and part of a disseminated disease. Treatment of brain metastasis has evolved over the years from whole brain radiotherapy (WBRT) only to multimodal therapy including surgical resection or stereotactic radiosurgery followed by WBRT and/or chemotherapy. The median survival after diagnosis of brain metastases was 6 months; nevertheless, a significantly better survival was achieved with multimodal therapy compared to WBRT only. It is suggested that brain imaging studies should be included in the followup of patients after treatment for ovarian carcinoma.

Prognostic factors associated with brain metastases from epithelial ovarian carcinoma

Brain metastasis from epithelial ovarian carcinoma (EOC) is managed by a multimodal treatment approach. Thus, to determine the prognostic factors associated with this situation is important for management decisions regarding the type of treatment and aggressiveness of treatment. From 1995 to 2005, 13 patients with brain metastases resulting from EOC underwent treatment at Samsung Medical Center. We retrospectively reviewed the medical records to determine prognostic factors and to evaluate treatment outcome. The median age at diagnosis for primary ovarian carcinoma and brain metastasis was 52 and 55 years, respectively. Median interval to brain metastases was 28 months after the diagnosis of EOC. At the time of analysis, nine patients had died of disease. The median survival from brain relapse was 7 months. A Karnofsky performance status of 70 or higher, primary control, solitary brain lesions, recursive partitioning analysis (RPA) class, and treatment modality including gamma-knife radiosurgery (GKRS) were related to survival on univariate analyses. Multivariate analysis showed that treatment modality including GKRS was a more important prognostic factor than RPA class (P= 0.04). This small series demonstrated that GKRS can be a valuable modality for the management of brain metastasis in patients with EOC. Therefore, a better outcome can be achieved by choosing GKRS in their treatments in selected patients.

Extent of extracranial disease is a powerful predictor of survival in patients with brain metastases from gynecological cancer

Central nervous system metastasis from gynecological malignancy is a rare phenomenon that has been described in the past 30 years. The objective of this study is to analyze the treatment modalities and prognostic factors for brain metastases from gynecological tumors that predict prolonged survival. A retrospective chart and pathology review of 47 patients diagnosed with a gynecological tumor with brain metastasis in 1994-2004 was performed. Thirty patients had undergone initial diagnosis and treatment at our institution, and 17 patients were referred following primary treatment at an outside institution. Adjusted Chi-square, Kaplan-Meier survival estimates, log-rank tests, and Cox regression analysis were utilized for statistical analysis of the total cohort. Of the 3146 patients with newly diagnosed gynecological cancer in this 10-year period, 30 developed brain metastasis demonstrating an incidence of 0.95%. Overall median survival from the time of diagnosis of brain metastasis was 7.5 months (95% CI 4-15, range 9 days-64 months) and 40% survival at 1 year. Multivariate analysis revealed evidence of extracranial disease at time of metastasis diagnosis predicted decreased survival (hazard ratio 6.207), while papillary serous histology (hazard ratio 0.42), and use of any chemotherapy (hazard ratio 0.24) predicted longer survival. No other patient or tumor characteristics were found to be independent prognostic indicators affecting survival. Despite the ominous prognosis associated with the development of brain metastasis, these retrospective data suggest that multimodal therapy with whole brain radiation therapy, chemotherapy, and surgical resection of metastases in selected patients without evidence of extracranial and with solitary or multiple lesions can prolong survival.

Gamma-knife radiosurgery for the treatment of ovarian cancer metastatic to the brain

BACKGROUND

Central nervous system (CNS) metastases from an ovarian malignancy are uncommon. The long-term prognosis for these patients is poor, with studies reporting a mean survival of less than 12 months.

CASES

We present three ovarian cancer patients who developed metastatic disease to the brain. All patients were heavily pre-treated prior to the development of CNS disease. Following detection of CNS disease, they all were treated with multi-modality therapy including gamma-knife radiosurgery (GKRS). At this time, one patient is alive at 26 months following treatment with GKRS. The second and third patients survived for 88 and 22 months respectively, before succumbing to their disease.

CONCLUSION

Local control of ovarian cancer metastatic to the brain can be achieved in some patients with GKRS. Additional investigation into GKRS is warranted.

Secondary cytoreductive surgery for recurrent epithelial ovarian carcinoma: proposal for patients selection

The value of secondary cytoreductive surgery (SCS) for recurrent ovarian cancer is still controversial. The aim of this study was to clarify candidates for SCS. Between January 1987 and September 2000, we performed SCS in 44 patients with recurrent ovarian cancer, according to our selection criteria, disease-free interval (DFI) >6 months, performance status <3, no apparent multiple diseases, age <75years and no progressive disease during preoperative chemotherapy, if undertaken. The variables were investigated by univariate and multivariate analyses. Of 44 patients, 26 (59.1%) achieved complete removal of all visible tumours at SCS. Secondary cytoreductive surgery outcome, complete or incomplete resection, was significantly related to overall survival (P=0.0019). As for variables determined before SCS, DFI >12 months, no liver metastasis, solitary tumour and tumour size <6 cm were independently associated with favourable overall survival after recurrence in the multivariate analysis. Patients with three or all four variables (n=31) had significantly better survival compared with the other patients (n=13) (47 vs 20 months in median survival, P<0.0001). In these patients, fairly good median survival (40 months) was obtained even in patients with incomplete resection. Secondary cytoreductive surgery had a large impact on survival of patients with recurrent ovarian cancer when they had three or all of the above-mentioned four factors at recurrence. These patients should be considered as ideal candidates for SCS.

Role of surgical resection for lung, liver, and central nervous system metastases in patients with gynecological cancer: a literature review

Many reports of ovarian, cervical, and uterine cancers metastatic to lung, liver, and brain have been published. A fewer number of them focused on the surgical treatment for these patients. We reviewed the published literature, regarding surgical management of metastatic disease in patients with gynecological cancer. Some prognostic factors in the patients with metastatic lesions from these three different cancers were found in common. Favorable prognostic factors for a prolonged survival were good performance status of the patients, long disease-free interval, absence of other systemic disease, and the resectability, preferably with a clear margin. These factors should be considered as the criteria for surgery. In well-selected patients, survival could be extended from the surgical procedure with minimal complications. Other types of treatment such as radiation therapy or chemotherapy could also be given in conjunction with surgery, depending on tumor type and disease status of the primary cancer, other systemic diseases, and residual metastatic lesions after surgery.

Brain metastases of epithelial ovarian carcinoma responding to cisplatin and gemcitabine combination chemotherapy: a case report and review of the literature

BACKGROUND

Brain represents a rare site of metastasis in patients with epithelial ovarian carcinoma (EOC).

CASE REPORT

We observed a case of multiple brain metastases in an EOC patient after complete response of a pelvic recurrence to platinum/paclitaxel chemotherapy. Complete response of brain metastases was observed after whole brain radiotherapy and subsequent chemotherapy by combination of cisplatin and gemcitabine. Three subsequent recurrences of brain metastases were controlled by re-treatment by the combination of 5-fluorouracil, cisplatin and gemcitabine.

METHODS

Because of limited information on the outcome of EOC brain metastases in reported case series, a pooled analysis of the published reports in patients with EOC brain metastases was performed. Data were extracted from 46 reports that contained sufficient details on 189 individual patients. The survival was analyzed by the Kaplan-Meier method. Univariate and multivariate analyses were performed by the log-rank test and Cox method, respectively.

RESULTS

The most favorable outcome was observed in patients treated by surgery combined with radiotherapy and/or chemotherapy. The survival was significantly better in reports describing only one or two cases, in patients diagnosed after 1992, in patients who received therapy in addition to symptomatic treatment, in patients treated by radiotherapy, chemotherapy and surgery, in patients without extracranial metastases and with single brain metastases. On multivariate analysis, the absence of extracranial metastases, treatment by chemotherapy, surgery and radiotherapy were independent positive predictors of survival.

CONCLUSIONS

EOC brain metastases are responsive to chemotherapy. An aggressive multidisciplinary therapeutic approach including chemotherapy may lead to prolonged survival.

A case of ovarian cancer with remote metastases, with emphasis on changes in tumor marker values

BACKGROUND

The prognosis of cancer patients with distant metastases is extremely poor.

CASE

A 51-year-old Japanese woman with Stage IIIc serous cystoadenocarcinoma of the ovary achieved complete remission. At 30 and 39 months after the initiation of therapy, solitary brain and then spleen metastases without intraperitoneal lesions were found, respectively. A simultaneous elevation in tumor markers (CA125 and CA72-4) was noted at the spleen metastasis; however, only a marked elevation in CA 72-4 levels at the brain metastasis was noted. Immunohistochemical studies revealed that although CA125-positive cells could be observed in both the original tumor and the spleen metastasis, CA125-positive cells could not be observed in the brain metastasis and that CA72-4-positive cells could be observed in both the original ovarian tumor and the metastatic tumor.

CONCLUSION

It is important to monitor with tumor markers with different characteristics, such as CA125 and CA72-4.

[Treatment of brain metastasis from ovarian cancer]

Systemic metastases from ovarian carcinoma are frequent, but they seldom affect the central nervous system. We present here the case of a patient treated for an ovarian cancer by surgery and chemotherapy. Three months after the end of chemotherapy, the patient developed cerebral metastases from ovarian carcinoma (CMOC) treated by iterative surgery and and whole brain irradiation. As the frequency of solitary cerebral metastasis of ovarian cancer is higher than with other cancers, it is likely that they behave slightly differently. Literature analysis reveals an increase in the incidence of CMOC since the middle of the nineties. CMOC can occur during or after adjuvant chemotherapy and the best management strategies to better define determinants of survival for patients are not well known. It appears that a better outcome of CMOC may be obtained by an aggressive treatment, if possible, including surgery, radiotherapy, and chemotherapy. Taking into account the increase in the incidence of the CMOC and their early occurrence, some authors have proposed a prophylactic brain radiotherapy in patients who receive adjuvant chemotherapy.

Successful treatment with stereotactic radiosurgery for brain metastases of endometrial carcinoma: a case report and review of the literature

Brain metastases from endometrial carcinomas are rare and the treatment is usually difficult. Here, we report a patient with stage IV endometrial carcinoma whose brain metastases showed complete remission after stereotactic radiosurgery using a gamma-knife. A 48-year-old woman underwent removal of a single brain metastatic lesion, and one month later underwent hysterectomy for endometrioid-type G3, endometrial adenocarcinoma. After hysterectomy, a cranial magnetic resonance imaging (MRI) demonstrated multiple brain metastases and the patient received two courses of stereotactic radiosurgery and six courses of chemotherapy. Complete response of the brain lesions was obtained, and she is well without recurrence 38 months after the second stereotactic radiosurgery.

Evaluation of prognostic factors and treatment modalities in ovarian cancer patients with brain metastases

OBJECTIVE

The objective of this study is to evaluate the impact of different clinical variables and treatment modalities on survival in patients with brain metastases from ovarian carcinoma.

METHODS

Methods included: (1) retrospective chart review of all patients with ovarian cancer and brain metastases from 1986 to 2000 at Roswell Park Cancer Institute and (2) Medline search was performed to extract data from all published reports with three or more cases of ovarian cancer with brain metastases. Cox regression analysis, Kaplan-Meier test, and log rank test were used to calculate survival and compare the impacts of clinical variables and treatment modalities.

RESULTS

Fifteen patients with brain metastases out of 1042 women with ovarian carcinoma were identified from our institution, an incidence of 1.4%. The median time from initial diagnosis to detection of brain metastases was 22 months. Patients who were not treated after brain metastasis had a median survival of 0.5 month versus 6 months with therapy. In the subgroup of patients treated with a combination of radiation, surgery, and chemotherapy, the median survival was 22 months. Literature analysis combined with our data generated 124 patients. The only clinically significant variable impacting survival was the presence or absence of additional distant recurrence with median survivals of 3 and 8 months, respectively (P = 0.005). Among patients who received treatment, the combination of radiation and surgery with or without chemotherapy appears to be beneficial, with a median survival of 20 months (P < 0.001).

CONCLUSION

Patients with brain metastases from ovarian cancer without any evidence of disease in other sites appear to benefit from aggressive combined treatment with external radiation and surgery with or without chemotherapy with a median survival of 20 months.

Brain metastases from epithelial ovarian carcinoma

BACKGROUND: Brain metastases from epithelial ovarian carcinoma are rare. We reviewed our experience to evaluate the results of different treatments and their prognosis. Discussion is based on a review of the literature. METHODS: From 1974 to 1998, eight of 704 patients treated for epithelial ovarian carcinoma at our large cancer center developed brain metastases. The median time before occurrence of brain metastases was 15 months after the diagnosis of the ovarian cancer. Six patients had a single lesion and two had multiple parenchymal lesions. Brain was the only site of disease in one patient, while seven had concomitant dissemination. Seven out of eight patients underwent a treatment for brain metastases. The treatment consisted of either radiotherapy (2 cases), chemotherapy (2 cases), surgery and radiotherapy (1 case), or combined treatment of the three modalities (2 cases). RESULTS: Median survival from diagnosis of brain lesions was 3 months (range 1-12). One patient without treatment died one month later. Survival after complete surgical resection and radiotherapy was 12 months. One patient treated by complete surgical resection followed by radiotherapy and chemotherapy is still alive (+ 5 months). The patient who underwent partial surgical resection followed by radiotherapy and chemotherapy died 7 months later. Two patients treated by radiotherapy alone died, respectively, 2 and 3 months later. After systemic chemotherapy alone, survival times were 1 and 3 months. Conclusions. The prognosis of patients with brain metastases from ovarian carcinoma is poor. A better outcome might be obtained by a multimodal treatment.

A patient with brain metastasis from ovarian cancer who showed complete remission after multidisciplinary treatment

We describe a case with brain metastasis from ovarian cancer who showed complete remission after multidisciplinary treatment. The case was diagnosed as epithelial ovarian cancer, FIGO stage IIIc. She underwent cisplatin-based chemotherapy after optimal cytoreductive surgery and achieved clinical complete remission. Thirty-two months after surgery for ovarian cancer, a solitary metastasis occurred in the left frontal lobe of the brain. No recurrent lesions were observed outside the brain. The metastatic tumor was resected. Five days after operation, adjuvant chemotherapy comprising carboplatin and cisplatin was initiated (a total of three courses at 4-week intervals), and whole brain irradiation at 55 Gy was added. After these treatment methods, complete remission of the brain metastasis has been observed for 57 months with good quality of life.