Colorectal carcinoma and brain metastasis: distribution, treatment, and survival

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.

Rectum to Medulla Oblongata: Colorectal Cancer Metastasizing to the Brainstem

Metastasis with colorectal cancer (CRC) is commonly seen in the liver, lungs and peritoneal cavity. Brainstem involvement with CRC is not studied with no prior reported cases. We report a case of CRC, admitted for apneic spells and dry cough and later found to have metastasis to the left anterolateral medulla oblongata. A 28-year-old male, with a past medical history of asthma, and colorectal adenocarcinoma metastatic to the brain, presented to the emergency department with complaints of a dry cough, altered mental status and shortness of breath. He was seen at urgent care before and was given a week of oral levofloxacin for presumptive pneumonia without any relief. Physical examination was concerning for stridor with clear lung fields. MRI brain showed previously noted post-operative right frontoparietal craniotomy changes and a new 9 x 8 x 8 mm ring-enhancing intra-axial lesion centered at the left anterolateral medulla oblongata indicative of brainstem metastatic disease. The patient was intubated for airway protection and underwent a suboccipital craniotomy for resection of the left pontomedullary mass, and histopathology was positive for metastatic adenocarcinoma, colorectal primary with hemorrhagic necrosis. He had a tracheostomy placed post multiple failed extubation trials and a gastrostomy tube for oral feeds. Goals of care were addressed with the patient and family, and a decision was made for home hospice.

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.

Prognostic factors following resection of intracranial metastases

Background:

The aim of this study was to identify prognostic factors associated with resection of intracranial metastases.

Methods:

A retrospective case series including patients who underwent resection of cranial metastases from March 2014 to April 2021 at a single center. This identified 112 patients who underwent 124 resections. The median age was 65 years old (24–84) and the most frequent primary cancers were nonsmall cell lung cancer (56%), breast adenocarcinoma (13%), melanoma (6%), and colorectal adenocarcinoma (6%). Postoperative MRI with contrast was performed within 48 hours in 56% of patients and radiation treatment was administered in 41%. GraphPad Prism 9.2.0 was used for the survival analysis.

Results:

At the time of data collection, 23% were still alive with a median follow-up of 1070 days (68–2484). The 30- and 90-day, and 1- and 5-year overall survival rates were 93%, 83%, 35%, and 17%, respectively. The most common causes of death within 90 days were as follows: unknown (32%), systemic or intracranial disease progression (26%), and pneumonia (21%). Age and extent of neurosurgical resection were associated with overall survival (P < 0.05). Patients aged >70 had a median survival of 5.4 months compared with 9.7, 11.4, and 11.4 for patients <50, 50–59, and 60–69, respectively. Gross-total resection achieved an overall survival of 11.8 months whereas sub-total, debulking, and unclear extent of resection led to a median survival of 5.7, 7.0, and 9.0 months, respectively.

Conclusion:

Age and extent of resection are potential predictors of long-term survival.

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.

Rectal cancer diagnosed after resection of isolated brain metastasis

Background

Brain metastasis of colorectal cancer is infrequent, and isolated brain metastases are more infrequent. Thus, when neurological symptoms, such as paralysis or disturbance of consciousness appear, there is a high probability that the cancer has spread to other organs.

Case presentation

Here, we present a 64-year-old man with a progressive headache, decreased motivation, and aphasia who was diagnosed with a brain tumor in the left frontal region. He underwent a craniotomy, and the brain tumor was diagnosed as adenocarcinoma. We performed a colonoscopy and diagnosed rectal cancer without other distant metastases. After whole-brain radiotherapy (WBRT), low anterior resection for primary rectal tumor was performed using a robotic system. The patient was discharged in good condition and received postoperative adjuvant therapy for rectal cancer. He showed no signs of recurrence after 1 year of follow-up.

Conclusions

We described a rare case of rectal cancer that was diagnosed after resection of isolated brain metastasis. A good prognosis was achieved with surgery and WBRT.

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.

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

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

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

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This case survived 19 years after the initial rectal surgery.

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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.

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.

Brain metastasis from colorectal cancer: clinical characteristics, timing, survival and prognostic factors

Background: Brain metastasis (BM) from colorectal cancer (CRC) seriously affects the survival and quality of life of patients. However, this disease is not fully understood. It is not clear when follow-up monitoring should be conducted to achieve early diagnosis. Furthermore, the reported prognostic factors have varied among different studies. Our study aims to determine the clinicopathological, survival and prognostic factors, as well as the timing of BM occurrence.Methods: We retrospectively studied the patients with BM from CRC between January 2000 and July 2017. The clinicopathologic features were assessed, and the time from primary tumor surgery and extracranial metastases (lung, liver and bone) to the occurrence of BM was calculated, respectively. Survival time after BM was statistically analyzed. Multivariate Cox analysis was carried out to determine the independent factors that affected survival.Results: 52 patients were analyzed. Most of the patients (86.5%) had combined extracranial metastases when BM was diagnosed, and lung was the commonest extracranial metastasis location. The median time interval from CRC surgery to the diagnosis of BM was 20.5 months, and the median time interval from lung, liver and bone metastases to BM was 7, 5 and 2 months, respectively. After diagnosis of BM, the median survival was 9 months. Extracranial metastases (p =.012) and Karnofsky performance status (p =.025) were independent prognostic factors based on multivariate analysis.Conclusion: BM from colorectal cancer often occur in the late stage, and has an extremely poor prognosis. Identifying the timing of brain metastasis can help to detect this disease early.

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.

Surgical Treatment following Chemo-Targeted Therapy with Bevacizumab for Lung Metastasis from Colorectal Carcinoma: Analysis of Safety and Histological Therapeutic Effects in Patients Treated at a Single Institution

Background

Recently, therapeutic strategies for a metastasectomy from colorectal carcinoma after chemo-targeted therapy with bevacizumab have been presented, with which some uncommon but serious adverse events have been reported. However, only few reports have investigated the safety of lung resection after such therapy or the histological effects. We retrospectively analyzed the both of them at our institute.

Methods

Of 69 colorectal carcinoma patients who underwent pulmonary metastasectomy procedures from 2009 to 2014, we investigated 11 who also received chemo-targeted therapy prior to surgery.

Results

In addition to bevacizumab, 5 fluorouracil (FU)/leucovorin + oxaliplatin or capecitabine was given in 6 cases and 5 FU/leucovorin + irinotecan in 5 cases. The mean period from the end of chemo-targeted therapy to surgery was 2.7 ± 0.9 months. The response to therapy shown in imaging findings was progressive disease in 6, stable disease in 3, and partial response in 2 (response rate, 18.2%). The operation modes were wedge resection (n = 8, 72.3%), segmentectomy (n = 2, 1 in bilateral lobes, 1 in the right lobe, 18.2%), and lobectomy (n = 1, left lower lobectomy, 9.1%). All patients safely underwent a complete resection. As for postsurgical complications, chylothorax occurred in 1 case and prolonged pulmonary air leakage in 1 case. The histological effects of chemo-targeted therapy were slight. There was no relationship between histological findings with imaging findings obtained prior to the operation (p = 0.63). The 5-year disease-free survival rate after metastasectomy was 10.9%.

Conclusions

Pulmonary metastasectomy after chemo-targeted therapy for colorectal carcinoma patients obtained acceptable results. In addition, there was no correlation between imaging and histopathologic results following chemo-targeted therapy.

A systematic review to assess the management of patients with cerebral metastases secondary to colorectal cancer

BACKGROUND

Colorectal cancer (CRC) rarely metastasizes to the brain. The incidence of cerebral metastases (CM) is estimated between 1 and 3%. Given the improved survival from advanced CRC as a result of surgical and oncological advances, it is anticipated that the incidence of patients with CM from CRC will rise over the next few years. The aim of this article was to systematically review the treatment options and outcome of patients with CM from CRC.

METHODS

PubMed and Medline databases were examined using the search words or MESH headings "colorectal" "cancer/carcinoma/adenocarcinoma", "cerebral"/"brain" and "metastases/metastasis".

RESULTS

CM from CRC are diagnosed on average 28.3 months after the primary tumour. The median survival time following diagnosis is 5.3 months. Surgery (with or without associated radiotherapy), stereotactic radiosurgery, whole brain radiotherapy and best supportive care result in median survival of 10.3, 6.4, 4.4 and 1.8 months, respectively. On average, the 1-year overall survival rate for patients with CM from CRC regardless of the treatment modality is estimated to be around 24%.

CONCLUSIONS

The prognosis of patients with CM from CRC is dismal. Surgery may increase survival, but the additional benefit of perioperative radiotherapy cannot be ascertained due to paucity of data. Further studies are required to identify the role of the different oncological and surgical therapies and identify those patients likely to benefit most. Identification of patients who are at higher risk of developing brain metastases may be another important area for future research.

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.

Clinical characteristics and treatment outcomes of patients with colorectal cancer who develop brain metastasis: a single institution experience

BACKGROUND

The development of brain metastasis (BM) in patients with colorectal cancer (CRC) is a rare and late event. We sought to investigate the clinical characteristics, disease course and safety using biologic agents in our patients with CRC who develop brain metastases.

METHODS

A retrospective review of patients with CRC with brain metastases treated at our institution from 01/2005-01/2015 was performed. Survival analysis was performed using the Kaplan-Meier method.

RESULTS

Forty patients were included in the analysis. Median age was 55.5 years, 67.5% were males, and 28% had a KRAS mutation. Twenty-four percent were treatment-naive at the time of BM diagnosis. Patients had a median of two brain lesions. Sixty-five percent of the patients were treated with radiotherapy alone, 22.5% had both surgical resection and brain radiotherapy. Median overall survival was 3.2 months after development of BM. Overall survival was longer in patients who received combined modality local therapy compared to patients treated with surgical resection or radiotherapy alone. Patients who received systemic treatment incorporating biologics following development of BM had a median overall survival of 18.6 months. Overall, the administration of biologic agents was safe and well tolerated.

CONCLUSIONS

In summary, BM is an uncommon and late event in the natural history of metastatic CRC. The ability to deliver combined-modality local brain therapy as well as availability of more systemic therapy options appear to lead to improved outcomes.

Brain metastasis in advanced colorectal cancer: results from the South Australian metastatic colorectal cancer (SAmCRC) registry

Objective:

Brain metastasis is considered rare in metastatic colorectal cancer (mCRC); thus, surveillance imaging does not routinely include the brain. The reported incidence of brain metastases ranges from 0.6% to 3.2%.

Methods:

The South Australian mCRC Registry (SAmCRC) was analyzed to assess the number of patients presenting with brain metastasis during their lifetime. Due to small numbers, a descriptive analysis is presented.

Results:

Only 59 patients of 4,100 on the registry at the time of analysis had developed brain metastasis (1.4%). The clinical characteristics of those with brain metastasis were as follows: the median age was 65.3 years and 51% were female. Where the V-Ki-ras2 Kirsten rat sarcoma viral oncogene homolog (KRAS) mutation status of the tumor was known, the majority harbored a KRAS mutation (55%); 31 (53%) underwent craniotomy and 55 (93%) underwent whole-brain radiotherapy. The median survival time from diagnosis of brain metastasis was 4.2 months (95% confidence interval 2.9–5.5). Patients who underwent craniotomy and radiotherapy had superior survival compared to those who underwent whole-brain radiotherapy (8.5 months vs. 2.2 months, respectively). Data from the SAmCRC (a population-based registry) confirm that brain metastases are rare and the median time to development is approximately 2 years.

Conclusions:

Brain metastasis is a rare outcome in advanced CRC. Patients within the registry tended to be female, young in age, and harbored with higher rates of KRAS mutations. Whether routine surveillance brain scanning should be considered remains controversial given the relative rarity of developing brain metastases in mCRC and ultimately, most patients with central nervous system involvement die from their extracranial disease.

Bevacizumab in Combination with Chemotherapy for Colorectal Brain Metastasis

BACKGROUND

Brain metastases are rare in patients with colorectal cancer, but the incidence is expected to rise due to prolonged survival resulting from more effective regimens including anti-EGF-receptor and anti-angiogenic antibodies. Because of the potential fear of intracranial hemorrhage, patients with colorectal brain metastases have been excluded from clinical trials involving bevacizumab or aflibercept.

PATIENTS

Five patients with colorectal brain metastases treated with bevacizumab-containing chemotherapy regimen following either neurosurgery, radiosurgery, or whole-brain radiotherapy were identified between 2009 and 2014. The clinicopathological data and outcomes for these patients were reviewed.

RESULTS

Mean time to disease progression concerning brain metastases was 14.8 months (range 5-25). Overall survival was 26.2 months (range 7-42 months) and overall survival since diagnosis of brain metastases was 20.6 month (7-42). Best response was a partial response in two and a stable disease in three patients. Treatment-related adverse events were mild hypertension (grade 1), diarrhea (grade 1), and fatigue (grade 1). No intracranial hemorrhage was observed.

CONCLUSION

Bevacizumab in combination with chemotherapy is a feasible option for palliative treatment of patients with colorectal brain metastasis with a good safety profile.

Analysis of patients with colorectal cancer and brain metastases

Brain metastases from colorectal cancer (CRC) are relatively rare. However, the incidences of brain metastasis have increased. We investigated 516 CRC patients who developed recurrence or metastatic disease. We investigated the primary site, distant metastasis, histological type, clinical features of processes of death and neurological symptoms. Brain metastases were detected in 5.8%. Odds ratios were 6.89 for the lung metastasis (p < 0.001), 0.43 for the liver (p = 0.04). The survival after brain metastasis was significantly poor in multiple brain metastases (hazard ratio: 4.12; p = 0.03) and poor performance status (hazard ratio: 5.38; p = 0.003). Lung metastasis is a higher factor and liver metastasis is a lower factor of brain metastasis. Survival after brain metastasis was poor in multiple brain metastasis and poor performance status.

Comparison of the molecular profile of brain metastases from colorectal cancer and corresponding primary tumors

AIM

Little is known about molecular biology of brain metastasis (BM) from colorectal cancer and its concordance with matched primary tumors.

MATERIALS & METHODS

We identified 56 consecutive colorectal cancer patients who underwent neurosurgical resection of BM. Tumor samples were tested for KRAS, NRAS, BRAF and PIK3CA. The molecular profile of the brain lesion was compared with the corresponding primary tumor.

RESULTS

The molecular profile concordance rate was 95.1%. Median survival after neurosurgery was 5.5 months (95% CI: 4.7-6.3); median overall survival was 24.0 months (95% CI: 15.6-32.4).

CONCLUSION

In this cohort, we report a high frequency of KRAS mutations and a very high concordance rate between the molecular status of BM and that of matched primary tumors.

Ten-Year Survival of a Patient Treated with Stereotactic Gamma Knife Radiosurgery for Brain Metastases from Colon Cancer with Ovarian and Lymph Node Metastases: A Case Report

Brain metastasis from colorectal cancer is infrequent and carries a poor prognosis. Herein, we present a patient alive 10 years after the identification of a first brain metastasis from sigmoid colon cancer. A 39-year-old woman underwent sigmoidectomy for sigmoid colon cancer during an emergency operation for pelvic peritonitis. The pathological finding was moderately differentiated adenocarcinoma. Eleven months after the sigmoidectomy, a metastatic lesion was identified in the left ovary. Despite local radiotherapy followed by chemotherapy, the left ovarian lesion grew, so resection of the uterus and bilateral ovaries was performed. Adjuvant chemotherapy with tegafur-uracil (UFT)/calcium folinate (leucovorin, LV) was initiated. Seven months after resection of the ovarian lesion, brain metastases appeared in the bilateral frontal lobes and were treated with stereotactic Gamma Knife radiosurgery. Cervical and mediastinal lymph node metastases were also diagnosed, and irradiation of these lesions was performed. After radiotherapy, 10 courses of oxaliplatin and infused fluorouracil plus leucovorin (FOLFOX) were administered. During FOLFOX administration, recurrent left frontal lobe brain metastasis was diagnosed and treated with stereotactic Gamma Knife radiosurgery. In this case, the brain metastases were well treated with stereotactic Gamma Knife radiosurgery, and the systemic disease arising from sigmoid colon cancer has been kept under control with chemotherapies, surgical resection, and radiotherapy.

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.

Predicted survival in patients with brain metastases from colorectal cancer: Is a current nomogram helpful?

OBJECTIVE

To examine the clinical applicability of a new nomogram by comparing survival of patients with brain metastases from colorectal cancer treated with surgery and/or radiotherapy in the authors' institutions with nomogram-predicted median survival.

METHODS

Retrospective analysis of 64 patients treated with comparable approaches and during the same time period as the patients in the nomogram study. Points were assigned for age, performance status, number and site of brain metastases, as required for nomogram use.

RESULTS

In 46 patients (72%), the observed survival was shorter than the predicted median. The median deviation was -1.4 months. The nomogram underestimated the survival of patients treated with radiosurgery/surgery by a median of 4.2 months, whereas it overestimated the survival of patients treated with whole-brain radiotherapy (WBRT) by a median of 2.1 months (p=0.0001). Nevertheless, all 5 patients with predicted median survival ≤3 months died within 3 months. Among 8 patients with predicted median survival >12 months, 6 (75%) survived for >12 months. Not all prognostic factors in the nomogram correlated with survival. In the multivariate Cox model, only performance status and number of brain metastases were significant, both with p=0.0001.

CONCLUSION

Despite differences in prognostic factors and survival of many individual patients, especially those with intermediate prognosis, the nomogram performed promising in poor- and good-prognosis patients. Evaluation of separate prediction tools for patients treated with WBRT and more aggressive local approaches appears warranted in order to minimize the influence of better local control of the brain metastases.

Prognostic factors and multidisciplinary treatment modalities for brain metastases from colorectal cancer: analysis of 93 patients

Background

The purpose of this study was to review patient characteristics and evaluate the potential factors affecting prognosis in cases of brain metastasis (BM) from colorectal cancer (CRC).

Methods

We retrospectively reviewed 93 cases of BM from CRC in our hospital. Patient demographics, neurologic symptoms, and location and number of BMs were recorded. Factors analyzed included: age; sex; Karnofsky performance score; number of BMs; presence of extracranial metastases; dimensions; location of tumors; treatment modalities.

Results

The overall 1- and 2-year survival rates were 27.7 and 9.9 %. On multivariate analysis, the number of BMs, extracranial metastases and the initial treatment modalities were found to be independent prognostic factors for overall survival. Patients treated with surgical resection followed by WBRT or SRS had an improved prognosis relative to those treated with surgery alone (P = 0.02 and P = 0.02, respectively). No significance difference in survival rate was found between patients treated with SRS alone or SRS plus WBRT (P = 0.11).

Conclusions

Surgical resection of BMs from CRC in selected patients may help prolong survival. Additional radiotherapy following surgery is valuable in improving prognosis. Extracranial metastasis, multiple BM lesions and initial non operation can be considered as independent factors associated with poor prognosis.

Colorectal cancer: Metastases to a single organ

Colorectal cancer (CRC) is a common malignancy worldwide. In CRC patients, metastases are the main cause of cancer-related mortality. In a group of metastatic CRC patients, the metastases are limited to a single site (solitary organ); the liver and lungs are the most commonly involved sites. When metastatic disease is limited to the liver and/or lungs, the resectability of the metastatic lesions will dictate the management approach and the outcome. Less commonly, the site of solitary organ CRC metastasis is the peritoneum. In these patients, cytoreduction followed by hyperthermic intraperitoneal chemotherapy may improve the outcome. Rarely, CRC involves other organs, such as the brain, bone, adrenals and spleen, as the only site of metastatic disease. There are limited data to guide clinical practice in these cases. Here, we have reviewed the disease characteristics, management approaches and prognosis based on the metastatic disease site in patients with CRC with metastases to a single organ.

Colorectal cancer metastatic to the brain: analysis of prognostic factors and impact of KRAS mutations on presentation and outcome

BACKGROUND

Treatment concepts for metastatic colorectal cancer continue to evolve. While the presence of RAS mutations impacts systemic therapy, little is known about the influence of such mutations in patients with brain metastases.

PATIENTS AND METHODS

Pooled retrospective analysis was conducted of 57 patients with brain metastases from colorectal cancer treated in two different institutions (2005-2013).

RESULTS

The only mutations analyzed in a relatively large subgroup were KRAS mutations (14 wild type, 12 mutated). Mutation status was not associated with baseline characteristics such as number or location of metastases, and did not impact prognosis. Three factors were significantly associated with survival in multivariate analysis: Karnofsky Performance Status (KPS), management strategy, and systemic treatment. Median survival was 0.6 months with best supportive care, 3.0 months with initial whole-brain radiotherapy (WBRT), and 12.7 months if initial treatment included surgery or stereotactic radiosurgery (SRS), p = 0.0001. The survival difference between the WBRT and surgery/SRS groups was largest in patients with KPS 80-100.

CONCLUSION

Effective local treatment was a prerequisite for improved survival. The only significant prognostic baseline factor was KPS, which forms the basis of the diagnosis-specific graded prognostic assessment (DS-GPA) score. Thus, our results validate the DS-GPA in this patient population. So far, neither this nor other studies suggest a clinically important impact of KRAS mutations beyond their previously reported association with development of brain metastases. Studies focusing on patients who develop brain metastases early during the course of metastatic disease might be warranted, because the influence of different systemic therapies might be larger in this subgroup.

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.

A case of calcified metastatic colorectal adenocarcinoma mimicking a benign lesion: pitfalls in diagnosis

The radiological finding of a calcified intracranial lesion commonly represents a slow growing benign mass. Brain metastases originating from colorectal cancers are rare, occurring in approximately 2-3% of patients. Therefore the presence of a calcified brain lesion in a patient with a positive oncological history requires a high index of suspicion for brain metastases. Presented herein is a case of a frontoparietal calcified lesion initially overlooked as a benign tumour. Subsequent imaging following a neurological episode revealed a significant increase in size of the lesion with surrounding tissue oedema, prompting further investigation for suspicion of a calcified metastatic colorectal adenocarcinoma.

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.

The clinical and pathological features of 133 colorectal cancer patients with brain metastasis: a multicenter retrospective analysis of the Gastrointestinal Tumors Working Committee of the Turkish Oncology Group (TOG)

Brain metastasis in colorectal cancer is highly rare. In the present study, we aimed to determine the frequency of brain metastasis in colorectal cancer patients and to establish prognostic characteristics of colorectal cancer patients with brain metastasis. In this cross-sectional study, the medical files of colorectal cancer patients with brain metastases who were definitely diagnosed by histopathologically were retrospectively reviewed. Brain metastasis was detected in 2.7 % (n = 133) of 4,864 colorectal cancer patients. The majority of cases were male (53 %), older than 65 years (59 %), with rectum cancer (56 %), a poorly differentiated tumor (70 %); had adenocarcinoma histology (97 %), and metachronous metastasis (86 %); received chemotherapy at least once for metastatic disease before brain metastasis developed (72 %), had progression with lung metastasis before (51 %), and 26 % (n = 31) of patients with extracranial disease at time the diagnosis of brain metastasis had both lung and bone metastases. The mean follow-up duration was 51 months (range 5-92), and the mean survival was 25.8 months (95 % CI 20.4-29.3). Overall survival rates were 81 % in the first year, 42.3 % in the third year, and 15.7 % in the fifth year. In multiple variable analysis, the most important independent risk factor for overall survival was determined as the presence of lung metastasis (HR 1.43, 95 % CI 1.27-4.14; P = 0.012). Brain metastasis develops late in the period of colorectal cancer and prognosis in these patients is poor. However, early screening of brain metastases in patients with lung metastasis may improve survival outcomes with new treatment modalities.

Brain metastasis from gastrointestinal cancers: a systematic review

BACKGROUND

Brain metastases (BM) from the gastrointestinal tract (GIT) cancers are relatively rare. Despite those advances in diagnostic and treatment options, life expectancy and quality of life in these patients are still poor. In this review, we present an overview of the studies which have been previously performed as well as a comprehensive strategy for the assessment and treatment of BM from the GIT cancers.

METHOD

To obtain information on brain metastases from GIT, we performed a systematic review of Medline, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL). The collected data included patient characteristics, primary tumor data and brain metastases data.

RESULT

In our search of the literature, we found 74 studies between 1980 and 2011, which included 2538 patients with brain metastases originated from gastrointestinal cancer. Analysis of available data showed that among 2538 patients who had brain metastases from GIT, a total of 116 patients (4.57%) had esophageal cancer, 148 patients (5.83%) had gastric cancer, 233 patients (9.18%) had liver cancer, 13 patients had pancreas cancer (0.52%) and 2028 patients (79.90%) had colorectal cancer. The total median age of the patients was 58.9 years.

CONCLUSION

Brain metastases have been considered the most common structural neurological complication of systemic cancer. Due to poor prognosis they influence the survival rate as well as the quality of life of the patients. The treatment of cerebral metastasis depends on the patients' situation and the decisions of the treating physicians. The early awareness of a probable metastasis from GI to the brain will have a great influence on treatment outcomes as well as the survival rate and the quality-of-life of the patients.

Cerebellar, brainstem and spinal cord metastases from esophageal cancer following radiotherapy: A case report and literature review

Cerebellar, brainstem and spinal cord metastases from esophageal cancer following radiotherapy are extremely rare. The current study presents the case of a 74-year-old male who was admitted to the Zhejiang Cancer Hospital (Hangzhou, China) with a poorly-differentiated neuroendocrine carcinoma of the esophagus. Following radiotherapy, multiple abnormal signals in the brainstem and spinal cord were found on magnetic resonance imaging (MRI). Following palliative radiochemotherapy, the clinical symptoms and abnormal MRI signals in the brainstem and spinal cord were found to improve. This case revealed that brain metastasis from esophageal carcinoma may occur simultaneously with brainstem and spinal cord metastases.

Netrin-1 expression is an independent prognostic factor for poor patient survival in brain metastases

The multifunctional molecule netrin-1 is upregulated in various malignancies and has recently been presented as a major general player in tumorigenesis leading to tumor progression and maintenance in various animal models. However, there is still a lack of clinico-epidemiological data related to netrin-1 expression. Therefore, the aim of our study was to elucidate the association of netrin-1 expression and patient survival in brain metastases since those constitute one of the most limiting factors for patient prognosis. We investigated 104 brain metastases cases for netrin-1 expression using in-situ hybridization and immunohistochemistry with regard to clinical parameters such as patient survival and MRI data. Our data show that netrin-1 is strongly upregulated in most cancer subtypes. Univariate analyses revealed netrin-1 expression as a significant factor associated with poor patient survival in the total cohort of brain metastasis patients and in sub-entities such as non-small cell lung carcinomas. Interestingly, many cancer samples showed a strong nuclear netrin-1 signal which was recently linked to a truncated netrin-1 variant that enhances tumor growth. Nuclear netrin-1 expression was associated with poor patient survival in univariate as well as in multivariate analyses. Our data indicate both total and nuclear netrin-1 expression as prognostic factors in brain metastases patients in contrast to other prognostic markers in oncology such as patient age, number of brain metastases or Ki67 proliferation index. Therefore, nuclear netrin-1 expression constitutes one of the first reported molecular biomarkers for patient survival in brain metastases. Furthermore, netrin-1 may constitute a promising target for future anti-cancer treatment approaches in brain metastases.

Brain metastases from colorectal cancer: main clinical factors conditioning outcome

BACKGROUND

The aim of our study is to evaluate the outcome of patients affected by brain metastases from colorectal cancer and to correlate the outcome with prognostic factors.

METHODS

Patients were retrospectively evaluated. Survival distributions were estimated by using the Kaplan-Meier method. The log-rank test was used to assess the impact on survival of individual factors.

RESULTS

Among 41 patients (25M and 16F; median age 58), 58.5 % had rectal cancer and 39 % synchronous metastatic disease; 95 % had extracranial metastases, most common site was lung (87.8 %). Seven patients had synchronous brain metastases. Median overall survival after diagnosis of brain metastases was 5 months [95 % confidence interval 3-12 months]. Median survival from brain metastases diagnosis was 4.2 months in patients treated with radiotherapy (29.3 %), 11.9 months in those with radio- and chemotherapy (21.9 %) and 21.4 months in those with surgery with/without radiotherapy or chemotherapy (29.3 %) (P < 0.0001). On multivariate analysis, no independent prognostic factors were found for disease-free interval from diagnosis to brain metastases and overall survival; amount of chemotherapy before brain metastases have no statistically significant relation to brain-metastases-free-interval even if patients who received more than one line of chemotherapy have a longer median brain-metastases-free-interval than those who received less than one. KRAS was found mutated in 17/28 patients without statistically significant correlation to outcome due to the small sample size.

CONCLUSIONS

Prognosis of brain-metastases-patients is poor. An interesting tool is to evaluate the correlation of KRAS status and brain metastases with aim to tailor treatment and follow-up.

Olanzapine and Betamethasone Are Effective for the Treatment of Nausea and Vomiting due to Metastatic Brain Tumors of Rectal Cancer

Brain lesions originating from metastasis of colorectal cancer represent 3–5% of all brain metastases and are relatively rare. Of all distant metastases of colorectal cancer, those to the liver are detected in 22–29% of cases, while those to the lungs are detected in 8–18% of cases. In contrast, brain metastasis is quite rare, with a reported incidence ranging from 0.4 to 1.8%. Treatments for metastatic brain tumors include surgery, radiotherapy, chemotherapy and supportive care with steroids, etc. Untreated patients exhibit a median survival of only approximately 1 month. The choice of treatment for brain metastasis depends on the number of lesions, the patient's general condition, nerve findings and presence of other metastatic lesions. We herein report the case of a 78-year-old male who presented with brain metastases originating from rectal carcinoma. He suffered from nausea, vomiting, anorexia and vertigo during body movement. He received antiemetics, glycerol and whole brain radiation therapy; however, these treatments proved ineffective. Olanzapine therapy was started at a dose of 1.25 mg every night. The persistent nausea disappeared the next day, and the frequency of vomiting subsequently decreased. The patient was able to consume solid food. Olanzapine is an antipsychotic that has recently been used as palliative therapy for refractory nausea and vomiting in patients receiving chemotherapy. We consider that olanzapine was helpful as a means of supportive care for the treatment of nausea and vomiting due to brain metastasis.

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 ).

Clinical features and course of brain metastases in colorectal cancer: an experience from a single institution

OBJECTIVES

Brain metastases from colorectal cancer (crc) are quite rare. Here, we review the characteristics, presentation, and clinical course of such patients at our institution.

METHODS

We reviewed the medical records of patients with brain metastases from crc treated during 2000-2009. Associations between patient, tumour characteristics, treatment modality, and survival were assessed using the Kaplan-Meier method.

RESULTS

We identified 48 patients (25 men, 23 women) who developed brain metastases from crc. The median age at diagnosis of the brain metastases was 63 years (range: 37-84 years). In 23 of the patients (48%), the primary tumour occurred in the rectum. At diagnosis of brain metastases, 43 patients (90%) also had other systemic metastases (mainly pulmonary and hepatic). The median interval between diagnosis of the primary tumour and of the brain metastases was 24 months. Median survival after a diagnosis of brain metastasis from crc was 4 months (range: 1-13 months). We observed substantially better survival (13 months, p < 0.001) in patients treated with surgery followed by whole-brain radiotherapy (wbrt) than in those treated with radiotherapy or surgery alone. Sex, age, location and number of brain metastases, and timing of diagnosis did not affect survival.

CONCLUSIONS

Brain metastases from crc develop late in the course of the disease, given that most patients already have other secondary lesions. Prognosis in these patients is poor, with those receiving treatment with surgery and wbrt having the best overall survival. Early detection and treatment of brain metastases with new systemic therapies may improve outcomes.

Microfabricated mimics of in vivo structural cues for the study of guided tumor cell migration

Guided cell migration plays a crucial role in tumor metastasis, which is considered to be the major cause of death in cancer patients. Such behavior is regulated in part by micro/nanoscale topographical cues present in the parenchyma or stroma in the form of fiber-like and/or conduit-like structures (e.g., white matter tracts, blood/lymphatic vessels, subpial and subperitoneal spaces). In this paper we used soft lithography micromolding to develop a tissue culture polystyrene platform with a microscale surface pattern that was able to induce guided cell motility along/through fiber-/conduit-like structures. The migratory behaviors of primary (glioma) and metastatic (lung and colon) tumors excised from the brain were monitored via time-lapse microscopy at the single cell level. All the tumor cells exhibited axially persistent cell migration, with percentages of unidirectionally motile cells of 84.0 ± 3.5%, 58.3 ± 6.8% and 69.4 ± 5.4% for the glioma, lung, and colon tumor cells, respectively. Lung tumor cells showed the highest migratory velocities (41.8 ± 4.6 μm h(-1)) compared to glioma (24.0 ± 1.8 μm h(-1)) and colon (26.7 ± 2.8 μm h(-1)) tumor cells. This platform could potentially be used in conjunction with other biological assays to probe the mechanisms underlying the metastatic phenotype under guided cell migration conditions, and possibly by itself as an indicator of the effectiveness of treatments that target specific tumor cell motility behaviors.

The incidence and outcome of brain metastases after liver resection for colorectal cancer metastases

AIM

Brain metastases from colorectal cancer are rare, with an incidence of 0.6-4%. The risk and outcome of brain metastases after hepatic and pulmonary metastasectomy have not been previously described. This study aimed to determine the incidence, predictive factors, treatment and survival of patients developing colorectal brain metastases, who had previously undergone resection of hepatic metastases.

METHOD

A retrospective review was carried out of a prospectively maintained database of patients undergoing liver resection for colorectal metastases.

RESULTS

Fifty-two (4.0%) of 1304 patients were diagnosed with brain metastases. The annual incidence rate was 1.03% per person-year. In the majority of cases brain metastases were found as part of multifocal disease. Median survival was 3.2 months (95% CI: 2.3-4.1), but was best for six patients treated with potentially curative resection [median survival = 13.2 (range, 4.9-32.1) months]. Multivariate analysis showed that a lymph node-positive primary tumour [hazard ratio (HR) = 2.7, 95% CI: 1.8-6.19; P = 0.019], large liver metastases (> 6 cm) [HR = 2.23, 95% CI: 1.19-2.33; P = 0.012] and recurrent intrahepatic and extrahepatic disease [HR = 2.11, 95% CI: 1.2-4.62; P = 0.013] were independent predictors for the development of brain metastases.

CONCLUSION

The annual risk of developing brain metastases following liver resection for colorectal metastases is low, but highest for patients presenting with a Dukes' C primary tumour, large liver metastases or who subsequently develop disseminated disease. The overall survival from colorectal brain metastases is poor, but resection with curative intent offers patients their best chance of medium-term survival.

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.

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.

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.