Risk and patterns of brain metastases in colorectal cancer: 27-year experience

A case of solitary metastatic colon adenocarcinoma of the sternum: an unusual metastatic site

Colorectal cancer is a prevalent malignancy; it ranks as the third leading cause of cancer-related deaths globally. Despite the effectiveness of surgical intervention for primary tumors, ~30% of patients develop metastases, commonly in the regional lymph nodes, liver, lungs, and peritoneum. Bone metastasis is relatively rare but can occur, typically affecting vertebrae, pelvis, femur, and humerus. This study presents a 68-year-old patient with a history of locally advanced colon cancer who presented with a rapidly enlarging, painful sternal mass. Imaging and biopsy confirmed metastatic colon adenocarcinoma in the sternum. The patient was treated with radiation therapy, resulting in significant symptomatic relief and tumor reduction. This case highlights the rarity of sternal metastasis from colorectal cancer. Given the poor prognosis associated with skeletal metastases in colorectal cancer, this case emphasizes the need for vigilance in monitoring for atypical metastatic sites and the importance of tailored palliative care strategies.

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.

Surgical excision and radiotherapy for brain metastasis from colorectal cancer: How frailty and comorbidity indices influence outcome

The incidence of brain metastasis (BM) from colorectal cancer (CRC) is increasing. This study aims to identify the clinical prognosticators and evaluate the prognostic validity of common comorbidity indices in patients with BM from CRC. This retrospective single-center study analyzed 93 patients with BM from CRC who received surgical excision and/or radiotherapy. The clinical characteristics and prognostic indices including the 5-item modified frailty index (mFI-5) and prognostic nutritional index (PNI) were calculated from the collected patient data and analyzed. In this study, 66 (71.0%), 10 (10.8%), and 17 (18.3%) patients received whole-brain radiotherapy (WBRT) alone, surgery alone, and surgery plus WBRT, respectively. The median survival of all patients was 3.98 months (IQR: 1.74-7.99). The 2- and 3-year survival rates were 7.4% and 3.7%, respectively. Controlled primary tumor (p = 0.048), solitary BM (p = 0.001), surgery + radiation (p < 0.001), and greater PNI (p = 0.001) were independent predictors of favorable survival. In surgically treated patients, uncontrolled primary tumor (p = 0.006), presence of multiple BM (p < 0.001), and MFI-5 ≥ 2 (p = 0.038) were independent prognosticators. For patients who received WBRT, the presence of two (p = 0.004) or multiple (p < 0.001) BM and PNI (p < 0.001) were independent survival predictors MFI-5, multiple BM, and the status of the primary tumor were independent prognosticators for patients who underwent surgery for CRCBM. For patients who received WBRT, the PNI and the number of BM were independent survival predictors.

Where Are We Now and Where Might We Be Headed in Understanding and Managing Brain Metastases in Colorectal Cancer Patients?

OPINION STATEMENT

Compared to liver and lung metastases, brain metastases (BMs) from colorectal cancer (CRC) are rare and remain poorly investigated despite the anticipated rise in their incidence. CRC patients bearing BM have a dismal prognosis with a median survival of 3-6 months, significantly lower than that of patients with BM from other primary tumors, and of those with metastatic CRC manifesting extracranially. While liver and lung metastases from CRC have more codified treatment strategies, there is no consensus regarding the treatment of BM in CRC, and their management follows the approaches of BM from other solid tumors. Therapeutic strategies are driven by the number and localisation of the lesion, consisting in local treatments such as surgery, stereotactic radiosurgery, or whole-brain radiotherapy. Novel treatment modalities are slowly finding their way into this shy unconsented armatorium including immunotherapy, monoclonal antibodies, tyrosine kinase inhibitors, or a combination of those, among others.This article reviews the pioneering strategies aiming at understanding, diagnosing, and managing this disease, and discusses future directions, challenges, and potential innovations in each of these domains.

HIGHLIGHTS

• With the increasing survival in CRC, brain and other rare/late-onset metastases are rising. • Distal colon/rectal primary location, long-standing progressive lung metastases, and longer survival are risk factors for BM development in CRC. • Late diagnosis and lack of consensus treatment strategies make BM-CRC diagnosis very dismal. • Liquid biopsies using circulating tumor cells might offer excellent opportunities in the early diagnosis of BM-CRC and the search for therapeutic options. • Multi-modality treatment including surgical metastatic resection, postoperative SRS with/without WBRT, and chemotherapy is the best current treatment option. • Recent mid-sized clinical trials, case reports, and preclinical models show the potential of unconventional therapeutic approaches as monoclonal antibodies, targeted therapies, and immunotherapy. Graphical abstract.

Survival Outcome of Surgical Resection vs. Radiotherapy in Brain Metastasis From Colorectal Cancer: A Meta-Analysis

Background

The incidence of brain metastasis from colorectal cancer (CRC) increases along with the greater survival rate for CRC because of the advances in therapeutic modalities. Local treatment strategies for brain metastasis include surgical resection and radiotherapy. Nevertheless, given the incongruent literature, the optimal therapeutic approach remains to be investigated. This study aims to systematically compare the real-world survival outcome of surgical resection and radiotherapy in patients with brain metastasis from CRC.

Methods

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines (PROSPERO, ID: CRD42021240200), the Cochrane Library, Embase, and Medline were searched from the inception of the database to August 2021. Meta-analyses were conducted with results pooled using hazard ratios with corresponding 95% CIs to evaluate the overall survival (OS) following local treatment for brain metastasis from CRC. Summary effects were evaluated using a series of random-effect models.

Results

In this review, 17 retrospective studies comprising 1,438 participants were included. In comparison with radiotherapy, the OS of patients who received brain metastasectomy was generally longer (HR, 0.53; 95% CI, 0.47–0.60). Extracerebral metastases (HR, 1.58; 95% CI, 1.34–1.86) and multiple brain metastases (HR, 1.38; 95% CI, 1.10–1.72) were associated with worse survival outcomes.

Conclusions

For patients with brain metastasis from CRC, the current real-world evidence demonstrated the survival benefit of aggressive neurosurgical management in suitable patients. Additionally, patients with extracerebral metastases and multiple brain metastases had worse survival outcomes.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=240200.

Patients with colorectal cancer and brain metastasis: The relevance of extracranial metastatic patterns predicting time intervals to first occurrence of intracranial metastasis and survival

The aim of the study was to investigate the predictive impact of extracranial metastatic patterns on course of disease and survival in patients with colorectal cancer (CRC) and brain metastasis (BM). A total of 228 patients (134 male [59%], 94 female [41%]) with histologically proven CRC and BM were classified into different groups according to extracranial metastatic patterns. Time intervals to metastatic events and survival times from initial CRC diagnosis, extracranial and intracranial metastasis were analyzed. Extracranial organs mostly affected were liver (102 of 228 [44.7%]) and lung (96 of 228 [42.1%]). Liver and lung metastases were detected in 31 patients (13.6%). Calculated over the entire course of disease, patients with lung metastasis showed longer overall survival (OS) than patients with liver metastasis or patients without lung metastasis (43.9 vs 34.6 [P = .002] vs 35.0 months [P = .002]). From the date of initial CRC diagnosis, lung metastasis occurred later in CRC history than liver metastasis (24.3 vs 7.5 months). Once lung metastasis was diagnosed, BM occurred faster than in patients with liver metastasis (15.8 vs 26.0 months; Δ 10.2 months). Accordingly, OS from the diagnosis of liver metastasis was longer than from lung metastasis (27.1 vs 19.6 months [P = .08]). Once BM was present, patients with lung metastasis lived longer than patients with liver metastasis (3.8 vs 1.1 months [P = .028]). Shortest survival times in all survival categories analyzed revealed patients with concurrent liver and lung metastasis. Patients with CRC and BM form a heterogeneous cohort where extracranial metastasis to liver or lungs predicts survival.

Perioperative therapy in metastatic colorectal cancer: Pattern of use and survival outcomes

BACKGROUND

Multimodality therapy of metastatic colorectal cancer (mCRC) is currently considered the standard of care. The aim of this study was to evaluate the impact of perioperative therapy on surgical resection in mCRC.

METHODS

The National Cancer Database was analyzed for affected patients between 2004 and 2013. Univariate and multivariate analyses were done to identify factors associated with patient outcomes. Kaplan-Meier analysis and Cox proportional hazards models were used for the association between patient characteristics and survival.

RESULTS

About 61,940 patients with mCRC were identified. Mean age = 63.4 years (SD ± 14). About 69% had a colon primary and 32% had only one metastatic site. Only 49% of those who underwent surgery for both primary and metastatic sites received postoperative chemotherapy (p < .001). Negative prognostic factors included no chemotherapy received (hazard ratio [HR], 2.32; 2.27-2.37; p < .001), more than three metastatic sites (HR, 2.28; 2.09-2.48; p < .001), year of diagnosis between 2004 and 2008 (HR, 1.71; 1.15-1.20; p < .001) and colon tumor location with right worse than left-sided (HR, 1.21; 1.19-1.24; p < .001). Five-year overall survival for resection of the primary and metastatic site (28.2%) was higher than for no surgical treatment (4.7%).

CONCLUSION

Perioperative therapy was associated with improved survival, following resection of metastatic sites or primary tumor.

The effect of brain metastasis location on clinical outcomes: A review of the literature

It is common clinical practice to consider the location of a brain metastasis when making decisions regarding local therapies and, in some scenarios, estimating clinical outcomes, such as local disease control and patient survival. However, the location of a brain metastasis is not included in any validated prognostic nomogram and it is unclear if this is due to a lack of a relationship or a lack of support from published data. We performed a comprehensive review of the literature focusing on studies that have investigated a relationship between brain metastasis location and clinical outcomes, including patient survival. The vast majority of reports anatomically categorized brain metastases as supratentorial or infratentorial whereas some reports also considered other subdivisions of the brain, including different lobes or with particular areas defined as eloquent cortex. Results were variable across studies, with some finding a relationship between metastasis location and survival, but the majority finding either no relationship or a weak correlation that was not significant in the context of multivariable analysis. Here, we highlight the key findings and limitations of many studies, including how neurosurgical resection might influence the relative importance of metastasis location and in what ways future analyses may improve anatomical categorization and resection status.

Results of Whole Brain Radiation Therapy in Patients with Brain Metastases from Colorectal Carcinoma

Aims and background

Carcinoma of the colon-rectum is an infrequent cause of brain metastases, constituting 1-5% of all metastatic lesions to the brain. We reviewed our experience in the treatment of brain metastases from colorectal cancer to define the efficacy of whole brain radiation therapy as a palliative measure in this setting of patients.

Methods

Twenty-three consecutive cases of brain metastasis from colorectal cancer treated between 1999 and 2004 were identified in the files of the Division of Radiotherapy of the A Businco Regional Oncological Hospital, Cagliari. Their records were reviewed for patient and tumor characteristics and categorized according to the RTOG RPA classes.

Results

Fifteen patients (65%) had multiple metastases. Twenty-one patients (91%) showed extracranial metastases. Fourteen patients were classified as RTOG RPA class II and 9 class III. The median radiation dose delivered was 2000 cGy in 5 fractions in one week (range, 20-36 Gy). In 14 of 20 assessable patients (70%), symptomatic improvement was observed. The median follow-up and survival time for all the patients, 12 females and 11 males, was 3 months. In 3 patients only the cause of death was the brain metastasis.

Conclusions

Despite the disappointing survival time, external radiation therapy to the whole brain proved to be an efficacious palliative treatment for patients with multiple or inoperable brain metastasis from colorectal cancer.

Brain metastases in newly diagnosed colorectal cancer: a population-based study

Background

Population-based incidence evaluations and prognosis assessments of brain metastasis (BM) at diagnosis of colorectal cancer (CRC) are lacking. Our study sought to determine the incidence of BM in CRC patients, median survival of patients with BM, and the risk factors of BM in CRC.

Patients and methods

Patients diagnosed with CRC were identified using the Surveillance, Epidemiology, and End Results database. Multivariable logistic and Cox regression analyses were performed to identify predictors of the presence of BM at CRC diagnosis and the factors associated with poor survival. Kaplan–Meier analysis was used to estimate the survival difference between subgroups.

Results

We identified 170,793 adult patients diagnosed with CRC between 2010 and 2013. From these patients, we identified 401 patients with BM at the time of CRC diagnosis, which represents 0.23% of the entire patient CRC cohort and 1.3% of the patients with metastatic disease to any site. Median survival of patients with BM was 7.0 months, and the survival could increase to 15.59 months if there was no metastasis to other organs. We found that extracranial metastases number, tumor site, and pathology type were associated with BM at CRC diagnosis.

Conclusion

The findings of this study indicate the incidence and prognosis for patients with BM at the time of CRC diagnosis. Our findings lend support for positive treatment for BM without metastasis to other organs.

Prognostic value of distant metastasis sites and surgery in stage IV colorectal cancer: a population-based study

PURPOSE

We investigated the prognostic value of distant metastasis sites among patients with metastatic colorectal cancer (CRC) and the significance of metastasectomy and resection of the primary CRC.

METHODS

Between 2010 and 2014, patients diagnosed with metastatic colorectal adenocarcinoma were selected using the surveillance, epidemiology, and end results (SEER) database. The prognosis of these patients was compared according to the site of metastasis (liver, lung, bone, and brain). A total of 15,133 patients suffered from isolated organ involvement, while 5135 patients experienced multiple organ metastases.

RESULTS

In the isolated organ metastasis cohort, median overall survival (OS) for patients with liver, lung, bone, and brain metastases was 16, 20, 7, and 5 months, respectively. Patients with isolated lung metastases had better cancer-specific survival (CSS) and OS as compared to patients with metastases at any other sites (p < 0.0001 for both CSS and OS). Patients with isolated liver metastases had better prognosis as compared to patients with isolated bone or brain metastases (p < 0.0001 for both CSS and OS). Moreover, patients with a single metastatic site had better prognosis than patients with multiple organs involved (p < 0.0001 for both CSS and OS). Multivariate analysis in patients with isolated organ metastases demonstrated that age ≤ 60 years, rectal cancer, being married, non-black race, N0 stage, and surgery of the primary and distant lesions showed more favorable prognosis.

CONCLUSIONS

The metastatic site was an independent prognostic factor in stage IV colorectal cancer. Also, carefully chosen patients may benefit from surgery.

Brain Metastases from Colorectal Carcinoma

Aims and Background

Brain metastases are an unusual finding in patients with colorectal carcinoma. We wished to determine the clinical presentation, the time interval between the diagnosis of colorectal carcinoma and the appearance of brain metastases, and the overall survival.

Patient characteristics

The median age of our patients was 61 years. Brain metastases developed subsequently to the diagnosis of colorectal cancer in nine patients. All patients had neurologic symptoms. All patients had progressing systemic disease at the moment of intracranial presentation. Four patients received whole brain radiation therapy. The median survival was 11 weeks.

Discussion

The development of brain metastasis is a late event in the course of colorectal carcinoma and occurs most often in patients with extensive systemic disease that contraindi-cates surgical resection. Radiotherapy can improve the survival of this group of patients whereas the role of chemotherapy is still unclear due to the low frequency of such cases.

Brain metastases from colorectal cancer: characteristics and management

BACKGROUND

Brain metastases (BMs) are the most common intracranial neoplasms in adults, but they rarely arise from colorectal cancer (CRC). The objective of this study was to report an overview of the characteristics and current management of CRC BMs.

METHODS

A systematic review on CRC BMs was performed using Medline database from 1983 to 2015. The search was limited to studies published in English. Review articles, not relevant case report or studies or studies relating to animal and in vitro experiments were excluded.

RESULTS

BMs occurred in 0.06-4% of patients with CRC. Most BMs were metachronous and were associated with lung (27-92%) and liver (12-80%) metastases. Treatment options depended on the number of BMs, the general conditions of the patient and the presence of other metastases. Most frequent treatment was whole-brain radiotherapy (WBRT) alone (36%), with median overall survival comprised between 2 and 9 months. Median overall survival was better after surgery alone (from 3 to 16.2 months), or combined with WBRT (from 7.6 to 14 months). After stereotactic radiosurgery alone, overall survival could reach 9.5 months. Many favourable prognostic factors were identified, such as high Karnofsky performance status, low recursive partitioning analysis classes, lack of extracranial disease, low number of BMs and possibility to perform surgical treatment.

CONCLUSION

BMs from CRC are rare. In the presence of favourable prognostic factors, an aggressive management including surgical resection with or without WBRT or stereotactic radiosurgery can improve the overall survival.

Colon cancer metastasis to the sternum: palliative treatment with radiofrequency ablation and cement injection

Colon cancer metastasis to bone is extremely rare and has devastating consequences on patients' quality of life. Furthermore, radiofrequency ablation in conjunction with cementoplasty to nonweight bearing, flat bones has not been widely reported as palliative treatment for pain as a result of bone metastasis. Here, we present a case of a 47-year-old man who developed a sternal metastasis from an invasive adenocarcinoma of the colon originally diagnosed several years prior. The pain from the metastasis was originally treated with external beam radiation therapy, but after 6 weeks of continuous pain, it was retreated using radiofrequency ablation in conjunction with cementoplasty.

Systematic review: brain metastases from colorectal cancer--Incidence and patient characteristics

Background

Brain metastases (BM) from colorectal cancer (CRC) are a rare event. However, the implications for affected patients are severe, and the incidence has been reported to be increasing. For clinicians, knowledge about the characteristics associated with BM is important and could lead to earlier diagnosis and improved survival.

Method

In this paper, we describe the incidence as well as characteristics associated with BM based on a systematic review of the current literature, following the PRISMA guidelines.

Results

We show that the incidence of BM in CRC patients ranges from 0.6 to 3.2 %. BM are a late stage phenomenon, and young age, rectal primary and lung metastases are associated with increased risk of developing BM. Molecular markers such as KRAS, BRAF, NRAS mutation as well as an increase in CEA and CA19.9 levels are suggested predictors of brain involvement. However, only KRAS mutations are reasonably well investigated and associated with an increased risk of BM.

Conclusion

The incidence of BM from CRC is 0.6 to 3.2 % and did not seem to increase over time. Development of BM is associated with young age, lung metastases, rectal primary and KRAS mutation. Increased awareness of brain involvement in patients with these characteristics is necessary.

A new nomogram for estimating survival in patients with brain metastases secondary to colorectal cancer

BACKGROUND

The prognosis of brain metastases (BM) in colorectal cancer (CRC) is extremely poor, but the incidence is increasing. The performance of existing prognostic classifications such as recursive partitioning analysis (RPA) and graded prognostic assessment (GPA) has never been evaluated in this specific setting. Moreover, the development of nomograms for estimating survival in such patients could be extremely helpful for treating physicians.

PATIENTS AND METHODS

Between 2000 and 2013, data from 227 patients with BM from CRC were collected at 8 Italian institutions. Overall survival (OS) was estimated with the Kaplan-Meier method and statistical comparison between curves was performed using the log-rank test. The discriminative ability for OS of RPA and GPA was assessed by the Harrell C-index from univariable Cox models. Putative prognostic factors for OS were also studied by multivariable Cox analysis, using the Harrell C index to evaluate the model discriminative ability. After a backward variable selection, a nomogram was developed to predict median survival time from individual patient- and tumor-related characteristics. The nomogram was externally validated on an independent series.

RESULTS

After a median follow-up of 59 months, fifty percent of patients were still at risk at 5 months. The C index was 0.594 and 0.607 for the RPA and GPA classifications, respectively. The C-index associated with the final multivariable Cox model used for developing the nomogram was 0.643; the favorable prognostic factors for survival were lower age (p=0.061), better Karnofsky performance status (p<0.001), supratentorial site of BM (p<0.001), and lower number of BM (p=0.035). The C index evaluated on the validation series was 0.733, even better than in the development series; also, the calibration of nomogram predictions was good.

CONCLUSION

The C-index associated to the nomogram model was slightly higher than that obtained for the RPA and GPA classifications. Most importantly, the very satisfactory results of nomogram validation on the external series, make us confident that our instrument may assist in prognostic assessment, treatment decision making, and enrollment into clinical trials.

Brain Metastasis in Colorectal Cancer Patients: Survival and Analysis of Prognostic Factors

BACKGROUND

The purpose of the study was to characterize the rare cohort of patients (pts) with metastatic colorectal cancer (mCRC) and brain metastasis (BM) and to identify prognostic subgroups.

PATIENTS AND METHODS

In collaboration with the Munich Cancer Registry, pts with mCRC and BM who were diagnosed between 1998 and 2011 were identified. Survival from the time of first diagnosis of colorectal cancer (CRC) (OS-1), from the time of diagnosis of metastatic disease (OS-2) and of BM (OS-3) was calculated regarding (1) the temporal occurrence of extra- and intracranial metastasis (meta- vs. synchronous) and (2) tumor and patient characteristics. For survival analysis the Kaplan-Meier estimator and Cox regression models were used.

RESULTS

A total of 228 pts (134 male [59%], 94 female [41%]) were identified. The median age was 63 years (142 pts [62%] were 65 years of age or younger). Most pts presented with primary tumors staged T3/4, N+, Grade 2. The primary tumor was located predominantly in the left colon (155 pts; 68%), especially in the rectum (95 pts; 42%). Median OS-1 was 35.6 months (95% confidence interval [CI], 30.1-41.1 months), OS-2 was 16.5 months (95% CI, 13.9-19.1 months), and OS-3 was 2.0 months (95% CI, 1.5-2.5 months). Median time from first CRC diagnosis to BM was 29.2 months. Subsequent BM after extracranial metastasis were observed in 184 pts (80.7%), whereas 31 pts (13.6%) presented with solitary BM. Univariate analysis did not reveal a prognostic variable for overall survival after diagnosis of BM.

CONCLUSION

This study presents the largest number of pts with mCRC and BM analyzed to date. The results show that most mCRC pts develop BM as a late step in the course of disease. Median time from first CRC diagnosis to BM is 29.2 months. Only a few pts were diagnosed with BM early in the disease or with solitary BM. When BM is present survival is poor.

Prognostic factors for patients with advanced colorectal cancer and symptomatic brain metastases

BACKGROUND

Increased rates of long-term survival after CRC diagnosis are accompanied by increases in the incidence of BMs. Here, we retrospectively evaluated the outcomes of patients with BMs from CRC.

MATERIALS AND METHODS

We reviewed the records of 1364 patients with CRC treated between January 1999 and December 2010 at Kinki University Hospital in Japan. Twenty-five of these patients developed BMs. Log-rank tests and Cox regression analyses were used to assess potential prognostic factors for survival.

RESULTS

Among the patients with BMs, BMs developed a median of 25.3 (range, 11.4-111) months after primary CRC surgery. There was a median of 2 BMs per patient. Eleven patients had solitary BMs. Concomitant extracerebral metastases, particularly lung metastases, were found in 23 patients. Twenty-three patients were receiving systemic chemotherapy at the time of diagnosis with BMs. After the development of BMs, the median survival time (MST) was 2.8 months. The MST was 4.8 months among patients who underwent neurosurgical resection (n = 6) or stereotactic surgery (n = 9, including combined therapy in 2 patients) and 1.5 months among patients who underwent whole-brain radiotherapy only or best supportive care (n = 12). In multivariate analysis, single BMs and additional systemic chemotherapy after BMs diagnosis were significantly associated with overall survival (P = .022 and .023, respectively).

CONCLUSION

Our results suggest that advancements in continuing systemic chemotherapy prolong survival among patients with BMs from CRC. Clinicians should be especially aware of BMs in patients with lung metastases.

Prognostic factors and treatment effects in patients with curatively resected brain metastasis from colorectal cancer

BACKGROUND

Colorectal cancer infrequently causes brain metastasis, and the prognosis is poor.

OBJECTIVE

The aim of this study was to identify the prognostic factors associated with survival and outcome of treatment for patients with brain metastasis from colorectal cancer.

DESIGN

This is a retrospective study from a prospectively collected database.

SETTINGS

The investigation took place in a high-volume multidisciplinary tertiary cancer center in Japan.

PATIENTS

From 1979 to 2010, 113 consecutive patients who were treated for brain metastasis from colorectal cancer were identified.

MAIN OUTCOME MEASURES

The primary outcome measure was overall survival.

RESULTS

Sixty-three patients had neurosurgical resection (including curative resection for 46 patients) followed by whole brain radiotherapy, 9 had stereotactic radiosurgery, 30 had whole brain radiotherapy, and 11 had steroid and palliative care. As a whole, the overall median survival time from diagnosis of brain metastasis was 5.4 months (95% CI, 4.3-7.6 months), and the 1-year survival rate was 29% (95% CI, 22%-38%). In the group of patients who underwent curative neurosurgical resection, the overall median survival time was 15.2 months (95% CI, 9.2-17.8 months), and the 1-year survival rate was 57% (95% CI, 43%-71%). On multivariate analysis, 1 or 2 brain metastatic lesions, no extracranial metastatic lesions, and neurosurgical resection were independent favorable prognostic factors overall (p = 0.0057, 0.0197, and <0.0001), and 1 or 2 brain metastatic lesions, no extracranial metastatic lesion, and no emergence of secondary brain metastatic lesions were independent favorable prognostic factors in the group of patients who underwent curative neurosurgical resection (p = 0.0137, 0.0081, and 0.0010).

LIMITATIONS

This study was limited by its single-institute, retrospective, nonrandomized design and selection bias.

CONCLUSIONS

Neurosurgical resection in select patients is a reasonable option for brain metastasis from colorectal cancer, although it is not associated with long-term (5-year) survival. (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A121 ).

Brain metastases from colorectal cancer: the role of surgical resection in selected patients

AIM

Brain metastasis is infrequent in colorectal cancer patients, and the prognosis is poor. In this retrospective study survival and prognostic factors were determined in patients with brain metastasis from colorectal cancer.

METHOD

Between 1997 and 2006, 39 patients with brain metastasis from colorectal cancer who survived more than 1 month were identified. Data were collected with regard to patient characteristics, location and stage of the primary tumour, extent and location of metastatic disease, and treatment modalities used.

RESULTS

Most (79.5%) patients had pulmonary metastases before brain metastasis, and the brain was the site of solitary metastasis in only one patient. The most frequent symptom was weakness [18 (43.6%) patients]. Overall median survival was 5.0 months and the 1- and 2-year survival rates were 21.8 and 9.1%, respectively. Univariate analysis revealed uncontrolled extracranial metastases (P = 0.019), multiple brain lesions (P = 0.026), bilateral brain metastases (P = 0.032) and serum carcinoembryonic antigen levels greater than 5 ng/ml (P = 0.008) to be poor prognostic factors. The median survival after the diagnosis of brain metastasis was significantly longer in patients who underwent surgical resection (15.2 ± 8.0 months) than in those treated by other modalities (P = 0.001). Treatment modality was the only independent prognostic factor for overall survival in patients with brain metastases from colorectal cancers (P = 0.015).

CONCLUSION

Aggressive surgical resection in selected patients with brain metastases from colorectal cancer may prolong survival, even in the presence of extracranial metastatic lesions.

Brain metastasis from colorectal cancer: prognostic factors and survival

BACKGROUND

Colorectal cancer (CRC) rarely metastasizes to the brain, and the incidence rate has been reported to be 1-2%. Unfortunately, the median survival for patients with brain metastasis (BM) from CRC is short. In this study, we retrospectively investigated the BM from CRC and examined the prognostic factors.

METHODS

We retrospectively analyzed 29 CRC patients who developed BM; the lesions were diagnosed synchronously in 1 patient and metachronously in 28 patients.

RESULTS

After BM, the median survival time was 7.4 months. In the groups of patients who underwent surgical resection and radiation therapy, the median survival times were 8.3 and 7.4 months, respectively. The difference between the two groups was not statistically significant. The curability of the therapy for BM, number of BM, number of metastatic organs including the brain, and the CEA level at the time of treatment of the BM were significantly associated with the cancer-specific survival (P = 0.0044, 0.0229, 0.0019, and 0.0205, respectively).

CONCLUSIONS

The prognosis of patients with BM from CRC was associated with the curability of the therapy for BM, number of metastatic organs, and the serum CEA level. The modality of treatment had no significant impact on the outcome.

Brain metastases from colorectal carcinoma: a description of 60 cases in a single Chinese cancer center

The incidence of brain metastasis (BM) from colorectal carcinoma (CRC) is increasing. The objectives of the present study were to explore the clinical characteristics and potential prognostic factors in CRC patients with BM. Between April 1991 and December 2010, all CRC patients treated in the Sun Yat-sen University Cancer Center were retrospectively reviewed and 60 patients were identified to have BM (36 males and 24 females). The association between patients and their tumor characteristics, treatment modality, and survival were statistically analyzed. The median age at diagnosis of BM was 62.5 years. Fifty-three patients (88.3%) developed extracranial metastases at diagnosis of BM. The cause of death was systemic disease in 19 patients and neurological disease in 23 patients. Brain metastases were primarily treated with either whole brain radiation therapy (WBRT; 15 patients), stereotactic radiosurgery (SRS; nine patients), or surgical resection (seven patients). Ten patients received WBRT and SRS, and 19 patients (31.7%) were treated with steroids alone. The median survival after diagnosis of BM was 8 months (95% confidence interval = 4.2-11.8 months). Recursive partitioning analysis (RPA) class, the number of brain lesions, and treatment modality type were significantly associated with survival. Although BM from CRC is a late-stage phenomenon with an extremely poor prognosis, some subsets of patients would benefit from a multidisciplinary management strategy. A low RPA class and a limited number of brain lesions may predict increased survival after therapy for CRC patients with BM.

Multidisciplinary treatment of brain metastases derived from colorectal cancer incorporating stereotactic radiosurgery: analysis of 78 patients

BACKGROUND

We investigated the role of radiotherapy, including whole brain radiotherapy and stereotactic radiosurgery (SRS), and prognostic factors in patients with colorectal cancer (CRC) who developed brain metastases.

PATIENTS AND METHODS

The data of 78 patients who received multidisciplinary treatment from 1996 to 2007 were reviewed. Overall survival (OS), intracerebral control (ICC), and local control (LC) were retrospectively analyzed. Six potential prognostic factors were evaluated: age, gender, number of brain metastases, extracerebral metastases, recursive partitioning analysis (RPA) class, and interval from tumor diagnosis to radiotherapy.

RESULTS

The median OS and ICC for the entire cohort were 8 and 6 months, respectively. Surgical resection-incorporating treatment resulted in significant improvement in OS (P = .036). On multivariate analysis, OS and ICC were significantly correlated with lack of extracerebral metastases (P = .024 and P = .041, respectively), lower number of lesions (P < .001 and P = .007, respectively) and interval from primary CRC diagnosis (P < .001 and .005, respectively) whereas RPA class I-II demonstrated significance only for OS (P = .045). SRS-incorporating therapy revealed a 1-year LC probability of 85%. No association between LC and any of the potential prognostic factors was observed.

CONCLUSION

Our data indicate that surgery can prolong survival in CRC patients with brain metastases. SRS-incorporating treatment provides excellent LC rates and should be considered for patients with 1-3 lesions. The strong association between survival and the prognostic factors identified in this study highlights a patient subset that may potentially benefit from new, more aggressive therapies.

Brain metastases in colorectal cancer

AIM

The aim of this study is the presentation of brain secondaries associated with colorectal cancer.

PATIENTS AND METHODS

In the period between 1990 and 2009, 670 patients with colorectal cancer were treated.

RESULTS

From 670 patients, 5 patients were identified with brain metastases. The incidence was 0.73%. The median interval between the colorectal cancer and the development of the brain secondaries was 7.5 months. Median survival after the diagnosis of brain metastases was 4.3 months.

CONCLUSION

Brain metastases associated with colorectal cancer are relatively rare, but also a frequent cause of death.

Gastrointestinal cancer and brain metastasis: a rare and ominous sign

Metastatic brain tumors represent 20% to 40% of all intracranial neoplasms and are found most frequently in association with lung cancer (50%) and breast cancer (12%). Although brain metastases occur in <4% of all tumors of the gastrointestinal (GI) tract, the incidence of GI brain metastasis is rising in part due to more effective systemic treatments and prolonged survival of patients with GI cancer. Data were collected from 25 studies (11 colorectal, 7 esophageal, 2 gastric, 1 pancreatic, 1 intestinal, 3 all-inclusive GI tract cancer) and 13 case reports (4 pancreatic, 4 gallbladder, and 5 small bowel cancer). Brain metastases are found in 1% of colorectal cancer, 1.2% of esophageal cancer, 0.62% of gastric cancer, and 0.33% of pancreatic cancer cases. Surgical resection with whole brain radiation therapy (WBRT) has been associated with the longest median survival (38.4-262 weeks) compared with surgery alone (16.4-70.8 weeks), stereotactic radiosurgery (20-38 weeks), WBRT alone (7.2-16 weeks), or steroids (4-7 weeks). Survival in patients with brain metastasis from GI cancer was found to be diminished compared with metastases arising from the breast, lung, or kidney. Prolonged survival and improvement in clinical symptoms has been found to be best achieved with surgical resection and WBRT. Although early treatment has been linked to prolonged survival and improved quality of life, brain metastases represent a late manifestation of GI cancers and remain an ominous sign.

Brain metastases in colorectal cancers

BACKGROUND

Although colorectal cancer is the most common cancer in Singapore, brain metastases associated with colorectal primaries are quite rare, with reported incidences ranging from less than 1% to 4%. This is a review of the incidence, presentation, and prognosis of brain secondaries from colorectal primaries in our institution.

METHODS

From a prospectively collected database, 4378 patients underwent surgery for colorectal cancers between 1995 and 2003. Patients who developed brain metastases were identified and their records reviewed retrospectively.

RESULTS

Twenty-seven patients who developed brain metastases were identified, for an incidence of 0.62%. Seventy-one percent of the patients had a tumor in the rectum or sigmoid; 92.6% of patients had metachronous brain secondaries. The median interval between surgery for the primary tumor and the discovery of a brain secondary was 27.5 months. The lung was the most common site of concurrent metastatic disease, with the discovery of a brain secondary a median of 9.7 months after diagnosis of the lung lesion. All patients were symptomatic. The majority of the patients received nonsurgical treatment for the brain lesion. Median survival after diagnosis of brain secondaries was 2.4 months.

CONCLUSIONS

The poor survival of the patients in our series could be due to late diagnosis. It may be recommended that a brain scan be performed to screen for a brain secondary when lung and/or liver metastases are discovered, especially in a patient with a left-sided cancer. This may lead to earlier diagnosis, amenability to surgical treatment, and improved survival and quality of life.

Multidisciplinary management of colorectal brain metastases: a retrospective study

BACKGROUND

The incidence of brain metastases (BM) from colorectal cancer (CRC) is increasing, and the management of this previously rare complication at a single institution is reported.

METHODS

The records of all patients with BM from 1994 to 2005 were reviewed, and 49 patients (33 men, 16 women) with 102 BM from CRC were identified. Associations between patient and tumor characteristics, treatment modality, and survival were assessed.

RESULTS

The median age at diagnosis of BM from CRC was 66 years. Forty patients (82%) had other systemic disease. The median survival after a diagnosis of BM from CRC was 5.1 months. Fifteen patients (31%) underwent surgery at some point, 14 patients (29%) underwent stereotactic radiosurgery (SRS), and 42 patients (86%) received whole-brain radiotherapy during their management. Seven patients (14%) underwent upfront SRS. On multivariate analysis, a longer interval from diagnosis of CRC to diagnosis of BM was associated significantly with shorter survival (p = .01). Sex, Karnofsky performance status, tumor location, recursive partitioning analysis class, and initial treatment modality did not have an impact on survival.

CONCLUSIONS

Because BM from CRC are a late-stage phenomenon, the majority of patients in the current study had other systemic involvement, and survival after CNS involvement was poor. The results indicated that a high prevalence of systemic disease limits the proportion of patients who are strong candidates for upfront SRS, thereby limiting the impact that this modality has on outcomes in this population as a whole. Late development (>1 year after the primary tumor diagnosis) of CNS involvement may predict for poorer survival after therapy for patients with BM from CRC.

Brain metastases as the first sign of colon cancer

Cerebral metastases from colorectal cancer occur in 8% of cases. Diagnosis is usually made when primary disease and widespread metastases are already known. However, the detection of brain metastases as the first sign of colorectal carcinoma without any liver and/or lung involvement is extremely rare. Central nervous system metastases are more commonly seen in rectal cancer and often occur concurrently with lung metastasis. We report a case of a patient with brain metastases as the first clinical manifestation of an adenocarcinoma of caecum without any other organ involvement.

Changing patterns of bone and brain metastases in patients with colorectal cancer

BACKGROUND

Therapeutic advances for patients with metastatic colorectal cancer (CRC) have been associated with prolonged survival. This study was undertaken to test the hypothesis that expanded treatment options and resultant improved survival for patients with metastatic CRC are associated with an increased incidence of metastases at uncommon sites.

PATIENTS AND METHODS

Patients with metastatic CRC evaluated from 1993 to 2002 at the Fox Chase Cancer Center were identified. Medical records were abstracted to obtain the following: date of diagnosis/metastasis, primary tumor site, therapeutic agents received, survival, and site(s) of metastases.

RESULTS

The records of 1020 patients were reviewed. Incidence of bone and brain metastases were 10.4% (95% CI, 8.6%-12.4%) and 3% (95% CI, 2.2%-4.5%), respectively. Bone metastases were more common with increased numbers of active systemic agents received: 0 (3.7%), 1 (9.4%), 2 (10.9%), 3 (16.3%), and 4/5 (17.4%; P = 0.001; trend test). Patients receiving irinotecan or oxaliplatin were more likely to develop bone metastases (13.2% vs. 8.3%, P = 0.01 for irinotecan; 16.9% vs. 9%, P = 0.003 for oxaliplatin). Patients with primary rectal versus primary colon cancer were more likely to develop bone metastases (16% vs. 8.6%; P = 0.001). Patients with lung metastases were more likely to have bone metastases (16.1% vs. 6.4%; P < 0.0001) or brain metastases (6.2% vs. 1.2%; P < 0.0001) than those without.

CONCLUSION

These data demonstrate that the incidence of bone and brain metastases in patients with CRC is more common than previously reported and is associated with receipt of multiple systemic treatments. As survival improves for this patient population, clinicians should be aware of the potential for metastases at previously uncommon sites.

Brain metastasis from colorectal cancer

PURPOSE

The mechanism of brain metastasis is not well understood, but the affinity between cancer cells and neural tissues may be involved in the process. The aim of our study is to elucidate the involvement of neural cell adhesion molecule (NCAM) and therapeutic parameters in patients with brain metastasis from colorectal cancer.

METHODS

We retrospectively identified 17 patients with brain metastasis from colorectal cancer. Data were collected with regard to patients' characteristics, location, and stage of primary tumor, and extent and location of metastatic disease. NCAM histochemical staining was undertaken using a paraffin block, and compared with 56 Dukes C patients and 13 Dukes D patients.

RESULTS

Neural cell adhesion molecule expression was significantly higher in the primary tumors of the brain metastasis patients than in the lesions of the Dukes C and Dukes D control groups (p = 0.0004). Patients whose tumor was managed by radiosurgery survived longer than patients who had had whole brain radiation or those who had been left untreated.

CONCLUSION

The fact that NCAM expression was high in the primary tumors of brain metastasis patients suggests that the affinity of cancer cells to a particular organ is important for circulation-mediated metastasis. Controlling local tumors using radiosurgery is certainly going to play an important role in extending survival and improving the patient's quality of life (QOL).

Patients with brain metastases from gastrointestinal tract cancer treated with whole brain radiation therapy: Prognostic factors and survival

AIM: To identify the prognostic factors with regard to survival for patients with brain metastasis from primary tumors of the gastrointestinal tract.

METHODS: Nine hundred and sixteen patients with brain metastases, treated with whole brain radiation therapy (WBRT) between January 1985 and December 2000 at the Department of Radiation Oncology, University Hospital Freiburg, were analyzed retrospectively.

RESULTS: Fifty-seven patients presented with a primary tumor of the gastrointestinal tract (esophagus: n = 0, stomach: n = 10, colorectal: n = 47). Twenty-six patients had a solitary brain metastasis, 31 patients presented with multiple brain metastases. Surgical resection was performed in 25 patients. WBRT was applied with daily fractions of 2 Gray (Gy) or 3 Gy to a total dose of 50 Gy or 30 Gy, respectively. The interval between diagnoses of the primary tumors and brain metastases was 22.6 mo vs 8.0 mo for patients with primary tumors of the colon/rectum vs other primary tumors, respectively (P < 0.01, log-rank). Median overall survival for all patients with brain metastases (n = 916) was 3.4 mo and 3.2 mo for patients with gastrointestinal neoplasms. Patients with gastrointestinal primary tumors presented significantly more often with a solitary brain metastasis than patients with other primary tumors (P < 0.05, log-rank). In patients with gastrointestinal neoplasms (n = 57), the median overall survival was 5.8 mo for patients with solitary brain metastasis vs 2.7 mo for patients with multiple brain metastases (P < 0.01, log-rank). The median overall survival for patients with a Karnofsky performance status (KPS) ≥ 70 was 5.5 mo vs 2.1 mo for patients with KPS < 70 (P < 0.01, log-rank). At multivariate analysis (Cox Model) the performance status and the number of brain metastases were identified as independent prognostic factors for overall survival.

CONCLUSION: Brain metastases occur late in the course of gastrointestinal tumors. Pretherapeutic variables like KPS and the number of brain metastases have a profound influence on treatment outcome.

Single cerebral metastasis from colorectal adenocarcinoma

Single cases are described in 50% of reported intracranial metastases. Single cerebral metastasis from colorectal adenocarcinoma is not very common, with a frequency varying between 0.5% and 1%. In our institute between 1960 and 2000, 44 patients affected by single metastasis from colorectal carcinoma were surgically treated. Surgical treatment with postoperative radiant therapy is necessary. These patients show improved quality of life, above all in relation to the maintenance of functional autonomy during the survival period.

Incidence of brain metastases in a cohort of patients with carcinoma of the breast, colon, kidney, and lung and melanoma

BACKGROUND

The objective of this study was to report on the incidence of and factors related to the occurrence of central nervous system metastases in a cohort of patients who were diagnosed with colorectal, lung, breast, or kidney carcinoma or melanoma.

METHODS

Using the population-based Maastricht Cancer Registry (MCR), a cohort was created of patients with colorectal carcinoma (n = 720 patients), lung carcinoma (n = 938 patients), breast carcinoma (n = 802 patients), renal carcinoma (n = 114 patients), and melanoma (n = 150 patients). The patients had to live in the catchment area of the University Hospital Maastricht (UHM) and had to have been diagnosed at the UHM during the period 1986-1995. Patients with brain metastases were searched for by linking the MCR to the Neuro-Oncology Registry of the UHM. Radiology files were checked as well. Follow-up lasted until December 31, 1998.

RESULTS

Brain metastases were diagnosed in 232 patients (8.5%) in the cohort (n = 2724 patients). Of these patients, 84 patients were diagnosed with brain metastases within 1 month after their primary diagnosis, 82 patients were diagnosed with brain metastases within 1 year of their primary diagnosis, and 66 patients were diagnosed with brain metastases more than 1 year after their primary diagnosis. The cumulative incidence after 5 years was estimated at 16.3% in patients with lung carcinoma, 9.8% in patients with renal carcinoma, 7.4% in patients with melanoma, 5.0% in patients with breast carcinoma, and 1.2% in patients with colorectal carcinoma. The incidence was lower in patients age > or = 70 years compared with younger patients (breast and lung carcinoma), lower in patients who were diagnosed before 1991 compared with patients who were diagnosed after 1991 (breast and lung carcinoma), and lower in patients who had nonsmall cell lung carcinoma compared with patients who had small cell lung carcinoma.

CONCLUSIONS

The frequency of brain metastases in this cohort was highest in patients with lung carcinoma, followed by patients with renal carcinoma. There was no evidence of an increasing incidence of brain metastasis in patients with carcinoma of the breast or lung.