Brain metastases from hepatocellular carcinoma: prognostic factors and outcome: brain metastasis from HCC

Stereotactic Radiosurgery for Patients with Brain Metastases from Hepatopancreaticobiliary Cancers

BACKGROUND

The role of stereotactic radiosurgery (SRS) for patients with brain metastases from hepatopancreaticobiliary (HPB) cancers has yet to be established. The authors present a single-institution experience of patients with HPB cancers who underwent SRS when their cancer spread to the brain.

METHODS

We surveyed our Gamma Knife SRS data base of 18,000 patients for the years 1987-2022. In total, 19 metastatic HPB cancer patients (13 male) with 76 brain metastases were identified. The median age at SRS was 61 years (range: 48-83). The primary cancer sites were hepatocellular carcinoma (HCC, 11 patients), cholangiocarcinoma (CCC, 2 patients), and pancreatic carcinoma (PCC, 6 patients). The median Karnofsky Performance Score (KPS) was 80 (range: 50-90). Two patients underwent pre-SRS whole-brain fractionated radiation therapy (WBRT) and eight patients underwent pre-SRS surgical resection. All SRS was delivered in single session. The median margin dose was 18 Gy (range: 15-20). The median cumulative tumor volume was 8.1 cc (range: 1.0-44.2).

RESULTS

The median patient overall survival (OS) after SRS was 7 months (range 1-79 months). Four patients had documented local tumor progression after SRS at a median time of 8.5 months (range: 2-15) between SRS and progression. Out of 76 treated tumors, 72 tumors exhibited local control. The local tumor control rate per patient was 78.9%. The local tumor control per tumor was 94.7%. Four patients developed new brain metastases at a median of 6.5 months (range: 2-17) after SRS. No patient experienced adverse radiation effects (AREs). At the last follow-up, 18 patients had died, all from systemic disease progression.

CONCLUSIONS

Metastatic spread to the brain from HPB cancers occurs late in the course of the primary disease. In this study, all deceased patients ultimately died from primary disease progression. SRS is a non-invasive strategy that maximally preserves quality of life, and our results reported favorable outcomes compared to the existing literature. SRS should be considered as one of the primary management strategies for patients with brain metastatic spread from HPB cancer.

Hepatocellular carcinoma metastatic to the pituitary gland without an identifiable primary lesion

Hepatocellular carcinoma is one of the most common malignancies worldwide. However, brain metastases from this cancer are incredibly rare. While the hepatocellular carcinoma mortality rate in the United States has been increasing, hepatocellular carcinoma is rare among patients without underlying liver disease. Here we present a patient with a history of left optic nerve meningioma treated with stereotactic radiosurgery who presented with acute vision loss. Magnetic resonance imaging revealed an enhancing mass lesion in the region of the sella turcica. Neurosurgical histopathology revealed a metastatic lesion consistent with hepatocellular carcinoma. Systemic workup failed to identify a primary liver lesion.

Incidence, Risk Factors, and Prognosis of Patients with Hepatocellular Carcinoma and Brain Metastases

OBJECTIVE

Brain metastases significantly impact the clinical course of patients with hepatocellular carcinoma (HCC). This study aimed to examine the age-related incidence, demographics, and survival of patients with HCC and brain metastases.

METHODS

Data of HCC patients from 2010 to 2015 in the Surveillance, Epidemiology, and End Results (SEER) Registry were screened for the presence of brain metastases. They were stratified by age and ethnicity. Multivariable logistic and Cox regression analyses were used to identify factors associated with brain metastases and those with overall survival (OS) and liver cancer-specific survival (CSS), respectively.

RESULTS

A total of 141 HCC patients presenting with brain metastases were identified, accounting for 0.35% of all HCC patients and 2.37% of patients with metastatic disease. Among all HCC patients, the incidence rate was the highest among patients aged 30-49 years old (0.47%). Ethnicity was not associated with the presence of brain metastases at the time of HCC diagnosis. However, African-American patients presented with a significantly lower disease-specific survival [median time: 1 month; interquartile range (IQR): 0-3.0 months)]. Initial lung or bone metastasis was independently associated with an increased risk of the presence of brain metastases [odds ratio (OR): 12.62, 95% confidence interval (CI): 8.40-18.97] but was not associated with a worse OS or CSS among those with brain metastases.

CONCLUSION

This study identified the age-related incidence and risk factors of brain metastases in HCC patients. These results may contribute to the consideration of brain screening among patients with initial metastatic HCC with lung or bone metastases, and influence the counseling of this patient population regarding their prognosis.

Repeated surgery for hemorrhagic brain metastases from hepatocellular carcinoma: palliation or effective part of a multimodal treatment? A case-based approach

Brain metastases from hepatocellular carcinoma (HCCBM) are encountered very rarely in clinical practice, especially in western countries. Only a minority of patients undergoes resective surgery, as clinical picture is usually complex and presentation is often catastrophic with intra-cerebral hemorrhage (ICH). Neurosurgical intervention can be not only life-saving but may also alleviate significantly the burden of symptoms. We present the case of a patient with six metachronous hemorrhagic HCCBM in which emergent surgery extended survival by 9 months, of which seven spent in near-normal life quality, stressing the role of neurosurgery in the evaluation of HCCBM patients.

A rare case of solitary, isolated dural metastasis from hepatocellular carcinoma mimicking a meningioma

Background

Distinguishing an isolated metastatic dural tumor from a meningioma on imaging is challenging and may lead to a delay in treatment. Here, we present the first known case of isolated, solitary dural metastasis from hepatocellular carcinoma (HCC) mimicking a meningioma.

Case Description

A 64-year-old male with a history of liver cirrhosis presented with a 5.8 cm enhancing left parafalcine hemorrhagic dural-based mass extending across the midline. Cerebral angiography revealed a distal left anterior pseudoaneurysm, and tumor contrast blush with feeders from the left ophthalmic and right middle meningeal artery. The pseudoaneurysm was successfully embolized to stop the bleeding, followed by an uneventful bi-coronal frontal craniotomy for falcine tumor resection to relieve brain compression. Histopathological analysis of the dural-based tumor showed poorly differentiated carcinoma with positive albumin in situ hybridization and cytokeratin tumor markers, consistent with dural metastases from HCC.

Conclusion

When encountering a solitary, highly vascular mass bearing resemblance to a meningioma, it may be prudent to consider the possibility of a dural-based metastatic carcinoma.

Spontaneous Acute Epidural Hematoma Associated With Metastatic Hepatocellular Carcinoma: A Case Report

Spontaneous acute epidural hematoma (AEDH) co-occurring with metastatic hepatocellular carcinoma (HCC) of the skull is rare, with only 7 documented cases in existing literature. This report describes the case of a 42-year-old man who presented with decreased consciousness following intermittent headaches following minor head trauma. Computed tomography imaging revealed an AEDH, prompting surgical intervention. Despite preliminary assumptions linking the causes of the trauma, surgical exploration revealed no evidence of traumatic injury. Instead, an infiltrative soft-tissue mass within the skull was identified. Histopathological examination confirmed that the mass was a metastatic HCC. Despite the successful hematoma evacuation, the patient's neurological status did not improve. This case underscores the importance of considering metastatic disease in the differential diagnosis of AEDH, particularly in patients with a history of malignant tumors, irrespective of prior indications of bone metastasis. Furthermore, it emphasizes the need to enhance diagnostic and therapeutic strategies for such complex cases.

2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

2022 KLCA-NCC Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

Skull Base Metastasis from Hepatocellular Carcinoma: Clinical Presentation and Efficacy of Radiotherapy

Purpose

Skull base metastasis (SBM) from hepatocellular carcinoma (HCC) presents detrimental survival outcomes with cranial nerve symptoms; however, they have received little attention. This study aimed to investigate the clinical presentation and efficacy of radiation therapy (RT) in patients with SBM from HCC.

Patients and Methods

We identified patients with SBM from HCC in Yonsei Cancer Center from 2005 to 2019. Image evaluations and SBM-related symptoms were reviewed. Overall survival was calculated using the Kaplan–Meier method and compared through the Log rank test. The oligometastasis group included patients with less than five foci of tumors, while the extensive metastasis group presented five or more sites.

Results

The incidence of SBM from HCC was 1.5% (58/3793 patients), commonly found in the middle cranial fossa. SBM associated symptoms presented in 51 patients, and the most common were head and neck area pain, and orbital symptoms, The palliation rate after RT was 65% (24/39 patients) for overall symptoms and 83.3% (20/24 patients) for cranial nerve symptoms. In whole cohort, overall survival was analyzed, and the median overall survival of patients with oligometastasis was better than extensive metastasis (23.7 months vs 1.8 months, p < 0.001). In subgroup who received RT (39 patients), the median overall survival was 23.7 and 2.7 months for patients with oligo and extensive metastasis, respectively (p < 0.001).

Conclusion

This study confirmed clinical features of SBM from HCC. Overall survival was generally poor, but patients presenting oligometastasis seemed to have possibility of relative long-term survival. Although radiation was effective in SBM-induced symptom relief, dose–response relationship in local control rate and overall survival needs further studies with larger number of patients.

Safety and Efficacy of Sorafenib and Lenvatinib in Patients Who Underwent Surgery or Whole-Brain Radiotherapy for Brain Metastasis of Hepatocellular Carcinoma

Surgery or whole-brain radiotherapy (WBRT) for the management of brain metastasis of hepatocellular carcinoma (HCC) is associated with improved survival. However, the efficacy of multi-tyrosine kinase inhibitors (TKIs) and possible bleeding complications have not been studied in these patients. Therefore, this study aimed at investigating TKI safety and efficacy in these patients. We retrospectively reviewed 39 patients who underwent surgery or WBRT for brain metastasis of HCC. Intracranial tumor bleeding rates were compared between patients who did and did not receive TKIs. Survival outcomes were analyzed using the log-rank and Cox regression tests. A total of 22 and 7 patients received sorafenib and lenvatinib, respectively. The intracranial tumor bleeding rates were 61.5% and 70% in patients who did and did not receive TKIs, respectively (p > 0.99). Survival analysis revealed craniotomy (adjusted odds ratio [AOR]: 0.45, p = 0.04), a higher Karnofsky Performance Score (AOR: 0.97, p < 0.01), and TKI use (AOR: 0.26, p < 0.01) were positive prognostic factors for overall survival. TKIs were associated with better survival outcomes in patients who underwent surgery or WBRT for brain metastasis of HCC and did not increase intracranial bleeding. Therefore, TKIs are efficacious and safe for treating brain metastasis of HCC.

Hemorrhagic Brain Metastasis as an Initial Presentation of Hepatocellular Carcinoma in a Patient With Alcohol-Related Liver Cirrhosis: A Case Report and Review of Literature

Hepatocellular carcinoma (HCC) is the most common primary hepatic cancer. Although it usually presents as a liver mass, rarely HCC can have an initial presentation at an extrahepatic site before the diagnosis of the primary lesion in the liver. Even rarely was that brain metastasis as initial extrahepatic presentations. Furthermore, the initial presentation of HCC as brain metastases has been with most cases being secondary to hepatitis-related hepatoma. In this case report, we are presenting a rare and unusual case of hemorrhagic cerebral metastasis as an initial extrahepatic presentation of an alcohol-related hepatoma. Our case is the second case in the English literature that has been presented in such a way. Due to the uncommonness of presentation, there can be diagnostic dilemmas and delay in treatment. Therefore, a high level of suspicion is needed in the high-risk patients of HCC who present with unexplained or new neurological signs and symptoms. More exploration is warranted for clinical research and treatment guidelines for brain metastases of HCC to help improve survival and quality of life.

Noninvasively predict the micro-vascular invasion and histopathological grade of hepatocellular carcinoma with CT-derived radiomics

Objectives

Methods

Results

Conclusion

A Rare Occurrence of Scalp Metastasis in Hepatocellular Carcinoma: Case Report

Hepatocellular carcinoma (HCC) is the most prevalent primary liver malignancy and the fifth most common cancer worldwide. Extrahepatic spread in this type of cancer is most commonly seen in the lungs and lymph nodes and less commonly in the skeletal system. Skull metastases are exceedingly rare, with an incidence of 0.5 to 1.6% reported to date. We report a similar case of a middle-aged Asian male patient with parietal scalp swelling that was initially diagnosed as meningioma. Surgical resection was performed at a local facility. The abdominal computed tomography scan did not reveal any primary or metastatic lesion. After much deliberation, multiparametric magnetic resonance imaging was requested that showed multiple lesions in the liver. Metastatic scalp lesion should be considered a differential diagnosis in HCC regardless of liver symptoms.

Extrahepatic metastases from hepatocellular carcinoma: multimodality image evaluation

The most prevalent primary malignancy of the liver is hepatocellular carcinoma (HCC); its poor prognosis is mainly related to intrahepatic recurrence and extrahepatic metastases. However, survival from HCC has improved due to better control of the primary tumor, the development of newer treatment modalities, including liver transplant, together with advances in imaging techniques. Therefore, the significance of patient management as corresponds with distant metastases has increased; since the proper evaluation and detection of extrahepatic metastases is crucial to optimize potential therapy for patients. Conventional imaging like CT, MRI play crucial rule in patient's diagnosis and qualifying for a certain type of therapy. More recently, a molecular imaging tool with radiolabeled deoxyglucose and fluorocholine has proved its promising value as a complementary tool to conventional studies. In this review, the frequent sites of metastases and HCC spread are discussed as well as the imaging findings as seen by both conventional imaging techniques and by molecular imaging tools, namely 18F-Choline PET/CT, and FDG PET. The implications of guiding treatment planning have also been discussed.

Interferon-Induced Transmembrane Protein 3 Expression Upregulation Is Involved in Progression of Hepatocellular Carcinoma

Purpose

Interferon-induced transmembrane protein 3 (IFITM3) is a key signaling molecule regulating cell growth in some tumors, but its function and mechanism in hepatocellular carcinoma (HCC) remain unknown. Our study investigated the relationship between the expression of IFITM3 and HCC development. Material and Methods. IFITM3 expression was identified via multiple gene expression databases and investigated in HCC tissue samples. Then, PLC/PRF/5 cells were transfected with lentivirus to knock down and overexpress the expression of IFITM3. IFITM3 expression, cell proliferation, and migration were detected by qRT-PCR, western blotting, QuantiGene Plex 2.0 assay, immunohistochemistry, CCK-8, and wound healing tests. RNA-seq technology identified the PI3K/AKT/mTOR pathway as an IFITM3-related signaling pathway for investigation.

Results

IFITM3 expression was higher in HCC tissues than in adjacent normal tissues, and the level of IFITM3 was higher in HCC tissues with low differentiation and metastatic potential than in those with high/medium differentiation and without metastatic potential. A higher RNA level of IFITM3 was found in samples with IFITM3 rs12252-CC genotype rather than the TT genotype. Knockdown of IFITM3 in PLC/PRF/5 cells inhibited cell proliferation and migration, blocked the expression of the PI3K/AKT/mTOR signaling pathway, and decreased the expression of vimentin. The results were opposite with the overexpression of IFITM3.

Conclusion

Upregulation of IFITM3 plays a role in the development of HCC. Possibly through regulating HCC cell proliferation and migration, these effects are associated with the PI3K/AKT/mTOR signaling pathway. Upregulation of IFITM3 is also associated with the IFITM3 rs12252-CC genotype.

Metastatic renal cell carcinoma to the brain: optimizing patient selection for gamma knife radiosurgery

INTRODUCTION

The effects of single-fraction gamma knife radiosurgery (sf-GKRS) on patients with renal cell carcinoma (RCC) brain metastases (BM) in the era of targeted agents (TA) and immune checkpoint inhibitors (ICI) are insufficiently studied.

METHODS AND MATERIALS

Clear cell metastatic RCC patients treated with sf-GKRS due to BM in 2005-2014 at three European centres were retrospectively analysed (n = 43). Median follow-up was 56 months. Ninety-five percent had prior nephrectomy, 53% synchronous metastasis and 86% extracranial disease at first sf-GKRS. Karnofsky performance status (KPS) ranged from 60 to 100%. Outcome measures were overall survival (OS), local control (LC) and adverse radiation effects (ARE).

RESULTS

One hundred and ninety-four targets were irradiated. The median number of targets at first sf-GKRS was two. The median prescription dose was 22.0 Gy. Thirty-seven percent had repeated sf-GKRS. Eighty-eight percent received TA. LC rates at 12 and 18 months were 97% and 90%. Median OS from the first sf-GKRS was 15.7 months. Low serum albumin (HR for death 5.3), corticosteroid use pre-sf-GKRS (HR for death 5.8) and KPS < 80 (HR for death 9.1) were independently associated with worse OS. No further prognostic information was gleaned from MSKCC risk group, synchronous metastasis, age, number of BM or extracranial metastases. Other prognostic scores for BM radiosurgery, including DS-GPA, renal-GPA, LLV-SIR and CITV-SIR, again, did not add further prognostic value. ARE were seldom symptomatic and were associated with tumour volume, 10-Gy volume and pre-treatment perifocal oedema. ARE were less common among patients treated with TA within 1 month of sf-GKRS.

CONCLUSIONS

We identified albumin, corticosteroid use and KPS as independent prognostic factors for sf-GKRS of clear cell RCC BM. Studies focusing on the prognostic significance of albumin in sf-GKRS are rare. Further studies with a larger number of patients are warranted to confirm the above analytical outcome. Also, in keeping with previous studies, our data showed optimal rates of local tumour control and limited toxicity post radiosurgery, rendering GKRS the tool of choice in the management of RCC BM.

Combination of Anti-Programmed Death 1 Therapy and Apatinib for a Patient with Hepatocellular Carcinoma and Brain Metastasis: Case Report and Literature Review

BACKGROUND

Brain metastasis is rare in patients with hepatocellular carcinoma (HCC). The combination of an anti-programmed death 1 inhibitor and an anti-vascular endothelial growth factor drug provides therapeutic opportunities for refractory patients. So far, there are no data on the efficacy of these combined therapies for patients with HCC brain metastasis.

CASE DESCRIPTION

HCC brain metastasis was diagnosed in a 31-year-old man. First, he underwent left liver resection and cholecystectomy and recovered well postoperatively. The postoperative pathologic findings were consistent with HCC. Approximately 2 years later, he presented with persistent headache and underwent magnetic resonance imaging, which revealed a lesion in the left parietal lobe. Anti-programmed death 1 and anti-vascular endothelial growth factor drugs were administered in combination, but the lesion did not shrink after the combined treatment on repeat magnetic resonance imaging. Therefore, surgical removal of the brain lesion was performed 2 months later. The postoperative pathologic results showed coagulative necrosis.

CONCLUSIONS

This case report highlights the efficacy of toripalimab and apatinib in the management of brain metastasis from HCC.

2018 Korean Liver Cancer Association-National Cancer Center Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer globally and the fourth most common cancer in men in Korea, where the prevalence of chronic hepatitis B infection is high in middle-aged and elderly patients. These practice guidelines will provide useful and constructive advice for the clinical management of patients with HCC. A total of 44 experts in hepatology, oncology, surgery, radiology, and radiation oncology in the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2014 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions.

2018 Korean Liver Cancer Association-National Cancer Center Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer globally and the fourth most common cancer in men in Korea, where the prevalence of chronic hepatitis B infection is high in middle-aged and elderly patients. These practice guidelines will provide useful and constructive advice for the clinical management of patients with HCC. A total of 44 experts in hepatology, oncology, surgery, radiology and radiation oncology in the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2014 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions.

Efficacy and safety of external-beam radiation therapy for hepatocellular carcinoma: An overview of current evidence according to the different target population

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors. During the recent years, external-beam radiation therapy (EBRT) has been safely and effectively employed for the management of HCC. We overviewed the current evidence regarding the efficacy and safety of EBRT for HCC according to the different target population. PubMed database was searched for identifying English-language full-text articles regarding EBRT for the treatment of HCC. Search items were "hepatocellular carcinoma AND radiation therapy". Until now, preliminary evidence has suggested the following role of EBRT for HCC. 1) EBRT, especially stereotactic body radiation therapy, is an emerging choice of therapy for small HCC. 2) EBRT combined with non-surgical treatment can achieve an excellent intrahepatic tumor control and a potential survival benefit for huge HCC. 3)Adjunctive EBRT may improve the efficacy of transarterial chemoembolization for HCC with portal vein tumor thrombosis. 4) EBRT can relieve the pain and improve the quality of life for patients with extrahepatic metastases. 5) EBRT may be a bridge to liver transplantation by minimizing the tumor progression. 6) Adjunctive EBRT may reduce the tumor recurrence and improve the survival after resection. In summary, EBRT is a promising choice of treatment of HCC. However, more high-quality evidence is needed to further establish the status of EBRT for the management of HCC.

Control of intracranial disease is associated with improved survival in patients with brain metastasis from hepatocellular carcinoma

BACKGROUND

Brain metastasis is a rare event in patients with hepatocellular carcinoma (HCC). This retrospective study aimed to identify the prognostic factors and determine the outcomes of patients with brain metastases from HCC.

METHODS

About 86 patients with brain metastases (0.6%) from HCC were identified from two institutions; of them, 32 underwent tumor-removing surgery or stereotactic radiosurgery (SRS) with or without adjuvant whole brain radiotherapy (WBRT) (group 1), 30 had WBRT alone (group 2), and 24 received conservative treatment (group 3). Estimates for overall survival (OS) after brain metastases were determined, and clinical prognostic factors were identified.

RESULTS

The median OS after development of brain metastases was 50 days. About 75 (87.2%) patients had lung metastases at the time of brain metastasis diagnosis. Group 1 showed better OS, followed by group 2 and group 3, sequentially (p < 0.001). Univariate analyses showed that treatment with curative intent (surgery or SRS), Child-Pugh class A, alpha-fetoprotein level < 400 ng/ml, and recursive partitioning analysis classification I or II were associated with improved survival (p < 0.001, 0.002, 0.029, and 0.012, respectively). Multivariate analysis showed that treatment with curative intent and Child-Pugh class A was associated with improved OS (p < 0.001 and 0.009, respectively).

CONCLUSION

Although the overall prognosis of patients with brain metastases from HCC is extremely poor, patients actively treated with surgery or radiosurgery have prolonged survival, suggesting that interventions to control intracranial disease are important in these patients.

Predictive value of a nomogram for hepatocellular carcinoma with brain metastasis at initial diagnosis: A population-based study

Background

Population-based estimates of the incidence and prognosis of brain metastases at diagnosis of hepatocellular carcinoma (HCC) are lacking. The aim of this study was to characterize the incidence proportion and survival of newly diagnosed hepatocellular carcinoma with brain metastases (HCCBM).

Materials and methods

Data from Surveillance, Epidemiology, and End Results (SEER) program between 2010 and 2014 was evaluated. Patients with HCCBM were included. Multivariable logistic and Cox regression were performed to identify predictors of the presence of brain metastases at diagnosis and prognostic factors of overall survival (OS). We also built a nomogram based on Cox model to predict prognosis for HCCBM patients.

Results

We identified 97 patients with brain metastases at the time of diagnosis of HCC, representing 0.33% of the entire cohort. Logistic regression showed patients with bone or lung metastases had greater odds of having brain metastases at diagnosis. Median OS for HCCBM was 2.40 months. Cox regression revealed unmarried and bone metastases patients suffered significantly shorter survival time. A nomogram was developed with internal validation concordance index of 0.639.

Conclusions

This study provided population-based estimates of the incidence and prognosis for HCCBM patients. The nomogram could be a convenient individualized predictive tool for prognosis.

Brain metastases: epidemiology

Brain metastases (BM) are the most commonly diagnosed type of central nervous system tumor in the United States. Estimates of the frequency of BM vary significantly, as there is no nationwide reporting system for metastases. BM may be the first sign of a previously undiagnosed cancer, or occur years or decades after the primary cancer was diagnosed. Incidence of BM varies significantly by primary cancer site. Lung, breast, and melanoma continue to be the leading cause of BM. These tumors are increasingly more common as new therapeutics, advanced imaging, and improved screening have led to lengthened survival after primary diagnosis for cancer patients. BM are difficult to treat, and for most individuals the diagnosis of BM generally portends a poor prognosis.

Clinical outcomes of brain metastases from hepatocellular carcinoma: a multicenter retrospective study and a literature review

INTRODUCTION

The introduction of systemic chemotherapy for advanced hepatocellular carcinoma in recent years has led to the prediction that cases of brain metastases from hepatocellular carcinoma will increase. However, because brain metastases from hepatocellular carcinoma are relatively rare, the characteristics of this pathology are poorly understood.

METHODS

We carried out a multicenter retrospective study to verify the characteristics of brain metastases from hepatocellular carcinoma in Japan.

RESULTS

A total of 38 patients were enrolled and patient characteristics were poor general condition in many patients due to the progression of primary cancers. Stereotactic radiosurgery/stereotactic radiotherapy alone was the most common treatment (39.5%), with best supportive care provided for 10.5%. Median survival was 6 months, the neurological death rate was 28%, and the rate of brain hemorrhage was high (39.5%). Overall survival was analyzed for correlations with age, etiology of chronic liver disease, albumin-bilirubin (ALBI) grade, RPA classification, control of the primary tumor, number of brain metastases, brain hemorrhage, surgical resection, and radiotherapy. In multivariate analysis, ALBI grade, number of brain metastases and brain hemorrhage showed statistically significant correlation.

CONCLUSIONS

A multivariate analysis extracted three items-ALBI grade, number of brain metastases, and brain hemorrhage-as prognostic factors for survival of brain metastases from hepatocellular carcinoma.

Clinical features of brain metastases from hepatocellular carcinoma using gamma knife surgery

Background

Brain metastases from hepatocellular carcinoma (HCC) are rare, but their incidence is increasing because of developments in recent therapeutic advances. The purpose of this study was to investigate the characteristics of brain metastases from HCC, to evaluate the predictive factors, and to assess the efficacy of gamma knife surgery (GKS).

Method

A retrospective study was performed on patients with brain metastases from HCC who were treated at Tokyo Gamma Unit Center from 2005 to 2014.

Results

Nineteen patients were identified. The median age at diagnosis of brain metastases was 67.0 years. Fifteen patients were male and four patients were female. Six patients were infected with hepatitis B virus (HBV). Two patients were infected with hepatitis C virus (HCV). Eleven patients were not infected with HBV or HCV. The median interval from the diagnosis of HCC to brain metastases was 32.0 months. The median number of brain metastases was two. The median Karnofsky performance score at first GKS was 70. The median survival time following brain metastases was 21.0 weeks. Six-month and 1-year survival rates were 41.2 and 0%, respectively. One month after GKS, no tumor showed progressive disease. The HBV infection (positive vs. negative) was significantly associated with survival according to univariate analysis (p = 0.002).

Conclusions

The patients having brain metastases from HCC had poor prognosis and low performance state. Therefore, GKS is an acceptable option for controlling brain metastases from HCC because GKS is noninvasive remedy and local control is reasonable.

Knockdown of FOXK1 inhibited the proliferation, migration and invasion in hepatocellular carcinoma cells

FOXK1 (forkhead box k1), a member of the FOX family, is overexpressed in several types of solid tumors. However, the biological function of FOXK1 in hepatocellular carcinoma (HCC) remains poorly understood. In the present study, we investigated the expression status and functional roles of FOXK1 in HCC. Our results demonstrated that the expression of FOXK1 was significantly up-regulated in human HCC tissues and cell lines. In addition, down-regulation of FOXK1 suppressed the proliferation, migration and invasion of HCC cells in vitro, as well as attenuated tumor growth in nude mice model. We further elucidated that knockdown of FOXK1 down-regulated the protein expression levels of β-catenin, c-myc and cyclin D1 in HepG2 cells. In conclusion, the present study indicated that FOXK1 may act as an oncogene in human HCC, and knockdown of FOXK1 significantly inhibited HCC cell proliferation, migration and invasion, partly through the inactivation of Wnt/β-catenin signaling pathway. These findings suggest that FOXK1 may be a novel therapeutic target to treat HCC.

Bevacizumab and risk of intracranial hemorrhage in patients with brain metastases: a meta-analysis

Administration of bevacizumab to patients with brain metastases (BM) is controversial due to concerns about the increased risk of intracranial hemorrhage (ICH). This meta-analysis assessed whether the risk of ICH increases in BM patients receiving treatments that contain bevacizumab versus without. PubMed, Embase, Cochrane Library and annual meeting abstracts of the American Society of Clinical Oncology up to 13 November 2016 were searched for studies that referred to ICH complications due to bevacizumab in patients with BM. Eight studies involving 8713 patients were included in this analysis. Compared with the control arm without bevacizumab, the bevacizumab treatment arm did not exhibit a significant increase in ICH [odds ratio (OR) 1.20; 95% confidence intervals (CI) 0.69–2.09; P = 0.53]. Subgroup analyses with retrospective studies showed a similar result, although subgroup analyses with prospective studies failed. This meta-analysis revealed that bevacizumab does not significantly increase the risk of ICH in solid tumor patients with BM.

Laser-captured microglia in the Alzheimer's and Parkinson's brain reveal unique regional expression profiles and suggest a potential role for hepatitis B in the Alzheimer's brain

Expression array data from dozens of laboratories, including our own, show significant changes in expression of many genes in Alzheimer's disease (AD) patients compared with normal controls. These data typically rely on brain homogenates, and information about transcripts specific to microglia and other central nervous system (CNS) cell types, which far outnumber microglia-specific transcripts, is lost. We therefore used single-cell laser capture methods to assess the full range of microglia-specific expression changes that occur in different brain regions (substantia nigra and hippocampus CA1) and disease states (AD, Parkinson's disease, and normal controls). Two novel pathways, neuronal repair and viral processing were identified. Based on KEGG analysis (Kyoto Encyclopedia of Genes and Genomes, a collection of biological pathways), one of the most significant viruses was hepatitis B virus (HBV) (false discovery rate < 0.00000001). Immunohistochemical analysis using HBV-core antibody in HBV-positive control, amnestic mild cognitive impairment, and HBV-positive AD cases show increased HBV immunoreactivity as disease pathology increases. These results are the first, to our knowledge, to show regional differences in human microglia. In addition, these data reveal new functions for microglia and suggest a novel risk factor for AD.

Intraparenchymal Hemorrhage due to Brain Metastasis of Hepatocellular Carcinoma

Although extrahepatic metastases from hepatocellular carcinoma (HCC) are present in only 5–15% of cases, they are certainly factors associated with poor prognosis. The main sites include lung, lymph nodes, bones, and adrenal glands, in descending order. Metastasis in the central nervous system is extremely rare, and the incidences vary from 0.6 to 1.7%. We report a case of a 54-year-old man previously diagnosed with alcohol-induced cirrhosis of the liver and HCC. The patient was admitted presenting progressive left hemiparesis and headache which started 2 days earlier, with no history of cranioencephalic trauma. After admission, cranial computed tomography revealed an intraparenchymal hemorrhage area with surrounding edema in the right frontal lobe. An angioresonance requested showed a large extra-axial mass lesion located in the right frontal region with well-defined contours and predominantly hypointense signal on T2 sequence. At first, the radiological findings suggested meningioma as the first diagnostic hypothesis. However, the patient underwent surgery. The tumor was completely removed, and the morphological and immunohistochemical findings were consistent with metastatic hepatocarcinoma associated with meningioma. In postoperative care, the patient did not recover from the left hemiparesis and manifested Broca's aphasia. He had a survival time of 24 weeks, presenting acute liver failure as his cause of death. There is a lack of evidence supporting a specific management of patients with brain metastasis from HCC. Furthermore, there are no studies that evaluate different modalities of therapeutics in brain metastasis of HCC due to the rarity of this condition. Therefore, management must be individualized depending on probable prognostic factors in these patients.

Hemorrhage of brain metastasis is a poor prognostic factor in hepatocellular carcinoma patients

It is unclear whether hemorrhage of brain metastasis is a poor prognostic factor in patients with hepatocellular carcinoma. We conducted a retrospective cohort study to compare overall survival between hemorrhage and no-hemorrhage groups of hepatocellular carcinoma patients with brain metastasis. Hepatocellular carcinoma patients with brain metastasis treated between June 2000 and June 2016 at the Cancer Hospital of Guangxi Medical University were retrospectively reviewed. Clinical characteristics and overall survival were compared between patients with (n = 11) and without (n = 25) hemorrhage of brain metastasis. Univariate and multivariate survival analyses showed hemorrhage to be a poor prognostic factor (hazard ratio = 5.812, 95% confidence interval: 1.399-24.142, p = 0.015). Patients with hemorrhage had a shorter median survival than those without hemorrhage (4 weeks vs 8 weeks, p = 0.001). These results suggest hemorrhage of brain metastasis is a poor prognostic factor in patients with hepatocellular carcinoma patients.

Brain metastases from hepatocellular carcinoma: recent advances and future avenues

The incidence of brain metastases from hepatocellular carcinoma (BMHCC) is becoming more frequent than that of the past as a result of prolonged survival of patients with HCC. Compared with brain metastases from other types of cancer, BMHCC tends to exhibit a high incidence of intracerebral hemorrhage (ICH) and poor liver function. Unfortunately, the prognosis is extremely poor for patients with BMHCC owing to the limited treatment selection. Currently, optimal treatment requires multidisciplinary approaches including surgery, whole-brain radiation therapy and stereotactic radiosurgery. Besides these traditional approaches, novel treatments such as target therapy and immunotherapy provide an opportunity to improve the survival of these patients. This review provides an overview of the incidence, characteristics, prognosis, and current and potential future management strategies for BMHCC.

Hepatocellular carcinoma with intracranial metastasis in a Japanese macaque (Macaca fuscata)

BACKGROUND

A 23-year-old male Japanese macaque (Macaca fuscata) showed left ptosis, which progressed to exophthalmos.

METHODS

The macaque underwent a clinical examination, CT and MRI, and was euthanized. Necropsy and histopathological examination were performed after euthanasia.

RESULTS

The CT revealed and MRI confirmed an intracranial mass at the skull base with orbital extension. At necropsy, there were a large hepatic mass and an intracranial mass compressing the left temporal lobe of the brain. Histopathological and immunohistological examinations revealed that the masses were hepatocellular carcinoma (HCC) and a metastatic lesion. In both the primary and metastatic lesions, neoplastic hepatocytes were arranged mainly in a trabecular pattern. Immunohistochemically, the tumor cells were positive for cytokeratin (AE1/AE3 and CAM5.2) and hepatocyte paraffin 1 and negative for cytokeratin 7 and 20 and vimentin.

CONCLUSION

To our knowledge, this is the first case report of HCC with intracranial metastasis in a macaque.

Tumor markers for early diagnosis for brain metastasis of hepatocellular carcinoma: A case series and literature review for effective loco-regional treatment

Intrahepatic lesions of hepatocellular carcinoma (HCC) have been controlled by significant advances in treatment using loco-regional therapies, including, surgery, ablative therapy, catheter-based chemotherapy, and embolization. Consequently, the number of patients with extrahepatic metastatic lesions has increased. Their prognosis remains poor with approximately <1 y of survival from the time of diagnosis. A molecularly targeted drug, sorafenib, have been used to treat extrahepatic lesions and shown the prolonged survival time. However, the therapeutic benefit for the brain metastasis remains unclear, since it causes intratumor bleeding leading to the severe brain damage. No guidelines for the brain metastasis of HCC have been developed to date due to the shortage of the experiences and evidences. Therefore, the development of standard therapy for brain metastasis following the early diagnosis is essential by accumulating the information of clinical courses and evidences. For this purpose, we reviewed cases of HCC brain metastasis reported to date and analyzed additional 8 cases from our hospital, reviewing 592 advanced HCC cases to estimate the possible metastatic lesions in the brain. With careful review of cases and literature, we suggest that the cases with lung metastasis with increase tendency of tumor markers within recent 3-6 months have higher risks of brain metastasis. Therefore, they should be carefully followed by imaging modalities. In addition, the loco-regional treatment, including surgical resection and radiation therapy should be performed for better prognosis by preventing re-bleeding from the tumors.

Diagnostic and therapeutic challenges in extragonadal yolk sac tumor with hepatoid differentiation: A case report

Yolk sac tumors (YSTs) are rare aggressive tumors, arising most commonly in the gonads and occurring mainly in young adults. We herein report a case of an extragonadal YST with hepatoid differentiation localized in the brain and lung. A 41-year old man presented to our hospital with a generalized seizure. A head computed tomography and magnetic resonance imaging examination revealed a large mass in the left occipital lobe with associated edema. Following complete resection, the histopathological examination revealed that the mass was a highly malignant epithelial tumor with a hepatoid pattern. The serum lactate dehydrogenase and α-fetoprotein levels were elevated. Additional diagnostic imaging revealed a lesion in the upper lobe of the right lung, but no other tumor manifestations. Based on the clinical and immunohistochemical characteristics, hepatocellular carcinoma and hepatoid adenocarcinoma were excluded and the diagnosis of extragonadal hepatoid YST was established. A multimodal therapeutic approach (high-dose chemotherapy with autologous stem cell transplantation, radiation and surgery) was applied; however, the patient succumbed to refractory disease 10 months after the diagnosis. Therefore, the diagnosis and treatment of hepatoid YST is an interdisciplinary challenge.

Application of radiotherapy for hepatocellular carcinoma in current clinical practice guidelines

In oncologic practice, treatment guidelines provide appropriate treatment strategies based on evidence. Currently, many guidelines are used, including those of the European Association for the Study of the Liver and European Organization for Research and Treatment of Cancer (EASL-EORTC), National Comprehensive Cancer Network (NCCN), Asia-Pacific Primary Liver Cancer Expert (APPLE), and Korean Liver Cancer Study Group and National Cancer Centre (KLCSG-NCC). Although radiotherapy is commonly used in clinical practice, some guidelines do not accept it as a standard treatment modality. In this review, we will investigate the clinical practice guidelines currently used, and discuss the application of radiotherapy.

The Largest Known Survival Analysis of Patients with Brain Metastasis from Thyroid Cancer Based on Prognostic Groups

PURPOSE

To analyze the clinical features and prognostic factors associated with the survival of patients with a very rare occurrence of brain metastasis (BM) from differentiated thyroid cancer (DTC).

METHODS AND MATERIALS

A total of 37 patients with DTC who were diagnosed with BM between 1995 and 2014 were included. We reviewed the clinical characteristics, treatment modalities, and image findings of BM. Factors associated with survival were evaluated, and the patients were divided into three prognostic groups (Groups A, B, and C) for comparative analysis.

RESULTS

The median age at BM was 63 years, and the median time from initial thyroid cancer diagnosis to BM was 3.8 years. The median survival and the 1-year actuarial survival rate after BM were 8.8 months and 47%, respectively. According to univariate and multivariate analyses, four good prognostic factors (GPFs) were identified including age ≤ 60 years, PS ≤ ECOG 2, ≤ 3 BM sites, and without extracranial metastasis prior to BM. Three prognostic groups were designed based on age and number of remaining GPFs: patients ≤ 60 years of age with at least 2 GPFs (Group A) had the most favorable prognosis with a median survival of 32.8 months; patients ≤ 60 years of age with fewer than 2 GPFs and those > 60 years of age with at least 2 GPFs (Group B) had an intermediate prognosis with a median survival of 9.4 months; and patients > 60 years of age with fewer than 2 GPFs (Group C) had the least favorable prognosis with a median survival of 1.5 months.

CONCLUSIONS

The survival of patients with BM form DTC differed among the prognostic groups based on the total number of good prognostic factors.

Brain metastasis from hepatocellular carcinoma: The impact of radiotherapy on control of intracranial hemorrhage

AIM

Brain metastasis from hepatocellular carcinoma (HCC) is rare and causes devastating outcomes with intracranial hemorrhage. We retrospectively analyzed the impact of radiotherapy in preventing hemorrhagic events among patients with brain metastasis from HCC.

METHODS

Patients who underwent treatment for brain metastasis from HCC at our cancer center between January 2003 and December 2012 were identified from a prospectively compiled hospital database. Clinical characteristics were analyzed in patients with and without radiotherapy.

RESULTS

Fifteen HCC patients with brain metastasis from HCC were classified into two groups: 11 patients underwent radiotherapy (group R) and four patients received best supportive care without radiotherapy (group N). Six patients (54.5%) in group R and four patients (100%) in group N showed intracranial hemorrhage at presentation of brain metastasis. No patients in group R experienced intracranial hemorrhage during follow up, although two patients in group N did. Median overall survival was 22.4 weeks (range, 5.42-69.1) in group R and 2.24 weeks (range, 1.0-15.4) in group N.

CONCLUSION

For patients with brain metastasis from HCC, radiotherapy appears useful for controlling brain lesions, preventing intracranial hemorrhage and improving survival. Radiotherapy may contribute to control of intracranial tumor and prevention of intracranial hemorrhage for selected patients with brain metastasis from HCC.

Nomogram prediction of survival in patients with brain metastases from hepatocellular carcinoma treated with whole-brain radiotherapy: a multicenter retrospective study

The incidence of brain metastasis from hepatocellular carcinoma (HCC) is increasing because of the improved survival outcome of HCC patients, but the prognosis of these patients is extremely poor. HCC patients with brain metastasis were investigated to identify their prognostic factors for overall survival. Patients with brain metastasis from HCC who had been treated with whole-brain radiotherapy (WBRT) in five hospitals were enrolled in the study. The medical records of the patients were reviewed, and the clinical factors were analyzed to identify the prognostic factors for overall survival. Of the total of 97 patients who were enrolled in the study, 83 were male and the median age at the brain metastases was 56.6 years. Motor weakness (43.3 %) and headache (41.2 %) were common presenting symptoms. The median AFP level was 4180 ng/ml, and 81 patients were assessed as belonging to Child-Pugh classification A upon the diagnosis of brain metastasis. WBRT alone in 71 patients, surgery or radiosurgery combined with WBRT as the adjuvant setting in 18 patients, and WBRT as salvage treatment in 8 patients were performed. The median overall survival of the patients was 3.5 months. In the multivariate analysis, the ECOG performance status (PS), Child-Pugh classification, AFP, and treatment aim showed significant association with the overall survival of the patients. Based on these factors, a nomogram predicting the prognosis was developed. The concordance index of the nomogram was 0.74, and the prediction was well calibrated. In conclusion, the survival outcome of patients with brain metastasis from HCC can be predicted with the nomogram constructed from the ECOG PS, Child-Pugh classification, AFP, and treatment aim.

Stereotactic radiosurgery in the treatment of brain metastases from gastrointestinal primaries

Brain metastases from gastrointestinal (GI) primary malignancies are generally less common than those arising from other primary locations. Our purpose was to analyze the efficacy of stereotactic radiosurgery (SRS) in the treatment of patients with brain metastases from GI malignancies in the modern radiosurgical and systemic therapy era. A review of patients treated with SRS to brain metastases from GI primaries treated from 1996 to 2015 at our institution was conducted. Clinical, therapeutic, dosimetric and radiographic characteristics were collected and analyzed for an association with brain tumor local control (LC) and overall survival (OS) following SRS using univariate and multivariate (MVA) analyses. 261 brain metastases were identified from 86 patients meeting inclusion criteria. The most common primary location was rectum (n = 36). LC was 94.1 % at last follow up and margin dose ≥20 Gy was associated with improved LC on MVA (p = 0.038). Median OS was 6.2 months and was improved with higher performance score and luminal primary location on MVA (p = 0.002 and 0.015, respectively). Tumor histology, whole brain irradiation, targeted therapies, and antineoplastic therapies were not associated with improved LC or OS on MVA. SRS provides favorable LC of brain metastases of GI origin, and margin doses of at least 20 Gy should be considered when clinically appropriate. Compared to non-luminal primaries, patients with brain metastases from a luminal primary demonstrate improved OS.

2014 KLCSG-NCC Korea Practice Guideline for the Management of Hepatocellular Carcinoma

The guideline for the management of hepatocellular carcinoma (HCC) was first developed in 2003 and revised in 2009 by the Korean Liver Cancer Study Group and the National Cancer Center, Korea. Since then, many studies on HCC have been carried out in Korea and other countries. In particular, a substantial body of knowledge has been accumulated on diagnosis, staging, and treatment specific to Asian characteristics, especially Koreans, prompting the proposal of new strategies. Accordingly, the new guideline presented herein was developed on the basis of recent evidence and expert opinions. The primary targets of this guideline are patients with suspicious or newly diagnosed HCC. This guideline provides recommendations for the initial treatment of patients with newly diagnosed HCC.

2014 Korean Liver Cancer Study Group-National Cancer Center Korea practice guideline for the management of hepatocellular carcinoma

The guideline for the management of hepatocellular carcinoma (HCC) was first developed in 2003 and revised in 2009 by the Korean Liver Cancer Study Group and the National Cancer Center, Korea. Since then, many studies on HCC have been carried out in Korea and other countries. In particular, a substantial body of knowledge has been accumulated on diagnosis, staging, and treatment specific to Asian characteristics, especially Koreans, prompting the proposal of new strategies. Accordingly, the new guideline presented herein was developed on the basis of recent evidence and expert opinions. The primary targets of this guideline are patients with suspicious or newly diagnosed HCC. This guideline provides recommendations for the initial treatment of patients with newly diagnosed HCC.

Concomitant Subdural Hemorrhage and Intracerebral Hemorrhage due to Brain Metastasis of the Hepatocellular Carcinoma

Hemorrhagic metastatic brain tumors of hepatocellular carcinoma (HCC) are rare and have been mostly presented as intracranial hemorrhage (ICH). A 51-year-old male patient presented with sudden altered level of consciousness. He suffered from HCC since 2010 and transarterial chemoembolization was performed three times for HCC. The brain computed tomography (CT) scans revealed subdural hematoma (SDH) in the right fronto-temporal area and 6.0×3.5 cm sized ICH in the right parieto-occipital lobe. Brain angiographic CT scans demonstrated that the hemorrhagic lesions did not include any enhancing lesions and vascular abnormalities. We undertook a decompressive craniectomy and evacuation of the acute SDH and ICH. During evacuation of ICH, the yellowish mass was observed in the cortical surface of the right occipital lobe. Pathological examination displayed the findings of metastatic brain tumor from HCC. Metastatic brain tumors should be considered in the differential diagnosis as a cause of spontaneous SDH with ICH.