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

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.

Validation of the graded prognostic assessment for gastrointestinal cancers with brain metastases (GI-GPA)

PURPOSE

The purpose of this study was to validate a new prognostic model (GI-GPA) originally derived from a multi-center database (USA, Canada, Japan).

PATIENTS AND METHODS

This retrospective study included 92 German and Norwegian patients treated with individualized approaches, always including brain radiotherapy. Information about age, extracranial spread, number of brain metastases, performance status and other variables was collected. The GI-GPA score was calculated as described by Sperduto et al. RESULTS: Median survival was 4 months. The corresponding figures for the 4 different prognostic strata were 2.3, 4.4, 9.4 and 12.7 months, respectively (p = 0.0001). Patients whose management included surgical resection had longer median survival than those who were treated with other approaches (median 11.9 versus 3.0 months, p = 0.002). Comparable results were seen for additional systemic therapy (median 8.5 versus 3.5 months, p = 0.01).

CONCLUSION

These results confirm the validity of the GI-GPA in an independent dataset from a different geographical region, despite the fact that overall survival was shorter in all prognostic strata, compared to Sperduto et al. Potential explanations include differences in molecular tumor characteristics and treatment selection, both brain metastases-directed and extracranially. Long-term survival beyond 5 years is possible in a small minority of patients.

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.

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.

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.

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.

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.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

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

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Gamma Knife surgery for brain metastases from colorectal cancer. Clinical article

OBJECT

The outcomes after Gamma Knife surgery (GKS) were retrospectively analyzed in patients with brain metastases from radioresistant primary colorectal cancer to evaluate the efficacy of GKS and the prognostic factors for local tumor control and overall survival.

METHODS

The authors reviewed the medical records of 152 patients with 616 tumors. The group included 102 men and 50 women aged 35-85 years (mean age 64.4 years), who underwent GKS for metastatic brain tumors from colorectal cancer between April 1992 and September 2008 at Yokohama Rosai Hospital.

RESULTS

The mean prescription dose to the tumor margin was 18.5 Gy (range 8-30 Gy). The mean tumor volume at GKS was 2.0 cm(3) (range 0.004-10.0 cm(3)). The primary tumors were located in the colon in 88 patients and the rectum in 64. The median interval between the diagnosis of primary lesions and the diagnosis of brain metastases was 27 months (range 0-180 months). The median neuroradiological follow-up period after GKS was 3 months (mean 6.4 months, range 1-93 months). The local tumor growth control rate, based on MR imaging, was 91.2%. The significant factors for unfavorable local tumor growth control, based on multivariate analysis, were larger tumor volume (p = 0.001) and lower margin dose (p = 0.016). The median overall survival time was 6 months. Lower Karnofsky Performance Scale (KPS) score (p = 0.026) and the presence of extracranial metastases (p = 0.004) at first GKS were significantly correlated with poor overall survival period in multivariate analysis. The cause of death was systemic disease in 112 patients and neurological disease in 13 patients. Leptomeningeal carcinomatosis was significantly correlated with a shorter duration of neurological survival in multivariate analysis (p < 0.0001).

CONCLUSIONS

Gamma Knife surgery is effective for suppression of local tumor growth in patients with brain metastases from radioresistant colorectal primary cancer. Therefore, clinical and radiological screening of intracranial metastases for patients with lower KPS scores and/or the presence of extracranial metastases as well as follow-up examinations after GKS for brain metastases should be performed periodically in patients with colorectal cancer, because the neurological prognosis is improved by initial and repeat GKS for newly diagnosed or recurrent tumors leading to a prolonged high-quality survival period.

Neurosurgical management and postoperative whole-brain radiotherapy for colorectal cancer patients with symptomatic brain metastases

BACKGROUND

New systemic treatments for advanced colorectal cancer have conferred a survival advantage, allowing patients to reach a median survival of almost 2 years. Due to this remarkable life extension, the incidence of brain metastases, though still low, is progressively increasing over time. There is little reported data on the optimal strategy to manage brain lesions from colorectal cancer.

METHODS

To explore the role of an aggressive approach to colorectal cancer brain metastases, we retrospectively collected and analyzed data from 30 patients who underwent neurosurgical resection + whole-brain radiotherapy between March 1998 and December 2006. Univariate (logrank) and multivariate (Cox's model) analyses were used to identify prognostic factors.

RESULTS

Median age at the time of surgery was 66 years, median ECOG PS was 1, most patients (87%) had concomitant lung and/or liver metastases. Median number of previous chemotherapies was two, with half of the patients being exposed both to oxaliplatin and irinotecan. A median of 27 Gy of radiotherapy were administered to 16 patients after resection. At the time of the analysis, 29 out of 30 patients had died, with a median survival time after brain metastasectomy of 167 days (8-682). Only one patient died within a month from surgery. Median survival was significantly longer in patients who received postsurgical radiotherapy (7.6 vs. 4.7 months, P = 0.014).

CONCLUSIONS

Neurosurgical management of symptomatic brain metastases from colorectal cancer is feasible, relatively safe, and offers a chance of prolonged survival. Patients who received radiotherapy after resection experienced a better outcome.

Multidisciplinary management of colorectal brain metastases: a retrospective study

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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