Little response of cerebral metastasis from hepatocellular carcinoma to any treatments

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.

Concurrent hepatocellular carcinoma metastasis to stomach, colon, and brain: A case report

BACKGROUND

Extrahepatic metastasis (EHM) from hepatocellular carcinoma (HCC) occurs in 10%–15% of cases following initial treatment. The most frequent sites of EHM are the lung, lymph nodes, and bone. Gastrointestinal or brain metastasis from HCC is rarely reported. Here, we report a rare case of concurrent HCC metastases to the stomach, colon, and brain.

CASE SUMMARY

A 72-year-old male with a history of alcohol induced HCC presented with multiple intrahepatic recurrences and tumorous lesions in the stomach and ascending colon. Three years earlier, he underwent right hemihepatectomy, and 1 year ago, he had a video-assisted thoracoscopic wedge resection for pulmonary metastasis of HCC. We decided on surgical resection of the new metastases because of massive gastric bleeding and concern for possible colonic obstruction. The patient underwent gastric wedge resection and right hemicolectomy. Two weeks later, the patient developed dysarthria and mild cognitive disorder. Magnetic resonance imaging of the brain revealed a left frontal lobe lesion, and he underwent resection of a metastatic brain tumor. Unfortunately, he died 6 weeks after the last surgery due to hepatorenal syndrome.

CONCLUSION

Decision of surgery was carefully recommended in this case and may extend survival in other metastatic HCC patients with well-preserved hepatic function.

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.

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.

The impact of liver resection on survival outcomes of hepatocellular carcinoma patients with extrahepatic metastases: A propensity score matching study

BACKGROUND

The majority of hepatocellular carcinoma patients (HCCs) with extrahepatic metastases die of progressive intrahepatic tumor. There have been little data on the role of primary tumor resection (PTR) for HCCs with extrahepatic metastases but with resectable primary tumors.

METHODS

A retrospective study was conducted on HCCs with extrahepatic metastases with resectable primary tumors who either underwent or did not undergo PTR in the SEER registry between 2004 and 2013. The overall and cancer-specific survivals (OS and CSS) were assessed by the log-rank test and the Cox proportional hazard regression model. A propensity score matching was conducted to minimize biases. Validation was performed in another cohort from the Sun Yat-sen Memorial Hospital (SYSMH).

RESULTS

Of the 529 HCCs with extrahepatic metastases with resectable primary tumors included into this study, 230 patients underwent PTR and 299 did not. The percentages of patients who underwent PTR increased from 38.6% in 2004 to 70.3% in 2013. In the propensity score-matched patients, PTR was associated with improved OS (HR 0.310, P < 0.001) and CSS (HR 0.326, P <0.001). These improvements in survivals remained significant after sensitivity analyses using multiple imputation. In the validation cohort from the SYSMH (n = 131), PTR was also correlated with improved OS (HR 0.508, P = 0.002) and CSS (HR 0.568, P = 0.017).

CONCLUSIONS

This study using propensity score matching and multiple imputation demonstrated that PTR had a favorable impact on the prognosis of HCCs with extrahepatic metastases with resectable primary tumors. Further prospective randomized trials are needed to confirm these findings.

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.

Simultaneous multitarget radiotherapy using helical tomotherapy and its combination with sorafenib for pulmonary metastases from hepatocellular carcinoma

We evaluated radiotherapy using helical tomotherapy (HT) combined with sorafenib for treatment of pulmonary metastases from hepatocellular carcinoma (HCC). We also analyzed potential prognostic factors and further validated the combination treatment. The objective response rate in the total cohort of 45 patients treated with HT (with or without sorafenib) was 66.7% (complete response, n = 1; partial response, n = 29), with no adverse events > grade 2 in severity. Median progression-free survival (PFS) and overall survival (OS) were 7.50 ± 0.53 and 26.40 ± 2.66 months, respectively. The addition of sorafenib was associated with increased PFS (11.80 ± 1.55 vs 5.80 ± 0.52 months, p = 0.006) and increased OS (29.60 ± 5.23 vs 21.90 ± 5.17 months, p = 0.007). After multivariate adjustment, the risk of disease progression associated with combination treatment was significantly lower (p = 0.022) compared with HT only, and survival was significantly longer (p = 0.014). Further validation confirmed the benefit of combination treatment. Prognostic factors were number of pulmonary metastases for PFS (19.00 ± 7.15 months for ≤3 lesions vs 5.80 ± 0.26 months for >3 lesions, p < 0.001) and intrahepatic tumor status for OS (28.50 ± 2.76 months for well-controlled tumors vs 15.60 ± 6.38 months for uncontrolled tumors, p = 0.011). In conclusion, radiotherapy with HT for pulmonary metastases is feasible without major complications, and its combination with sorafenib may be a promising approach in a subgroup of 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.

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.

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.

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.

Post-treatment intracranial hemorrhage of brain metastases from hepatocellular carcinoma

Purpose

To evaluate the incidence and risk factors of post-treatment intracranial hemorrhage of brain metastases from hepatocellular carcinoma (HCC).

Materials and Methods

Medical records of 81 patients who have been diagnosed of brain metastases from HCC and underwent surgery, radiosurgery and/or whole brain radiotherapy (WBRT) between January 2000 and December 2013 were retrospectively reviewed.

Results

Intracranial hemorrhage was present in 64 patients (79%) at the time of diagnosis. Median value of alpha-fetoprotein (AFP) level was 1,700 ng/mL. The Eastern Cooperative Oncology Group (ECOG) performance status for 20 patients was greater than 2. Fifty-seven patients underwent WBRT and the others were treated with surgery and/or radiosurgery without WBRT. During follow-up, 12 events of intracranial hemorrhage after treatment were identified. Three-month post-treatment hemorrhage rate was 16.1%. Multivariate analyses revealed that ECOG performance status, AFP, and WBRT were associated with post-treatment hemorrhage (p = 0.013, 0.013, and 0.003, respectively). Kaplan-Meier analysis showed that 3-month post-treatment hemorrhage rate of new lesion was higher in patients treated without WBRT, although statistical significance was not reached. (18.6% vs. 4.6%; p = 0.104). Ten of 12 patients with post-treatment hemorrhage died with neurologic cause.

Conclusion

WBRT should be considered to prevent post-treatment hemorrhage in the treatment of brain metastases from HCC.

Gamma Knife surgery for treating brain metastases arising from hepatocellular carcinomas

OBJECT

Brain metastases from hepatocellular carcinoma (HCC) are rare, and the evidence of the effectiveness of Gamma Knife surgery (GKS) in this disease is lacking. The authors report their institutional experience with GKS in patients with brain metastases from HCCs.

METHODS

The authors retrospectively reviewed the medical records of 73 consecutive patients who had a combined total of 141 brain metastases arising from HCCs and were treated with GKS. Sixty-four (87.7%) patients were male, and the mean age of the patients was 52.5 years (range 30-79 years). The mean tumor volume was 7.35 cm(3) (range 0.19-33.7 cm(3)). The median margin dose prescribed was 23 Gy (range 15-32 Gy). Univariate and multivariate survival analyses were performed to identify possible prognostic factors of outcomes.

RESULTS

The estimated rate of local tumor control was 79.6% at 3 months after GKS. The median overall survival time after GKS was 16 weeks. The actuarial survival rates were 76.7%, 58.9%, and 26.0% at 4, 12, and 24 weeks after GKS, respectively. In the univariate analysis, an age of ≤ 65 years, Child-Pugh Class A (pertaining to liver function), high Karnofsky Performance Scale score (≥ 70), and low Radiation Therapy Oncology Group recursive partitioning analysis class (I or II) were positively associated with the survival times of patients. No statistically significant variable was identified in the multivariate analysis.

CONCLUSIONS

Although survival was extremely poor in patients with brain metastases from HCCs, GKS showed acceptable local tumor control at 3 months after the treatment. The authors suggest that GKS represents a noninvasive approach that may provide a valuable option for treating patients with brain metastases from HCCs.

Role of radiotherapy in the management of hepatocellular carcinoma: A systematic review

Many patients with hepatocellular carcinoma (HCC) present with advanced disease, not amenable to curative therapies such as surgery, transplantation or radiofrequency ablation. Treatment options for this group of patients include transarterial chemoembolization (TACE) and radiation therapy. Especially TACE, delivering a highly concentrated dose of chemotherapy to tumor cells while minimizing systemic toxicity of chemotherapy, has given favorable results on local control and survival. Radiotherapy, as a therapeutic modality of internal radiation therapy with radioisotopes, has also achieved efficacious tumor control in advanced disease. On the contrary, the role of external beam radiotherapy for HCC has been limited in the past, due to the low tolerance of surrounding normal liver parenchyma. However, technological innovations in the field of radiotherapy treatment planning and delivery, have provided the means of delivering radical doses to the tumor, while sparing normal tissues. Advanced and highly conformal radiotherapy approaches such as stereotactic body radiotherapy and proton therapy, evaluated for efficacy and safety for HCC, report encouraging results. In this review, we present the role of radiotherapy in hepatocellular carcinoma patients not suitable for radical treatment.

Prognostic stratification of brain metastases from hepatocellular carcinoma

The aim of this study is to evaluate prognostic factors of brain metastases from hepatocellular carcinoma. Medical records of 95 patients who have been diagnosed of brain metastases from hepatocellular carcinoma between January 2000 and December 2011 were retrospectively reviewed. The median age at diagnosis of brain metastases is 56.1 years. Eighty-two patients were male. Median interval from diagnosis of hepatocellular carcinoma to brain metastases was 29.5 months. Eighty-eight patents had extracranial metastases, and the lung was the most frequent involved organ. Motor weakness was the most frequent presenting symptom (49.5%). Intracranial hemorrhage was present in 71 patients (74.7%). Brain metastases were treated with whole brain radiation therapy (WBRT) alone in 57 patients, radiosurgery alone in 18, surgery and WBRT in 6, surgery and radiosurgery in 3, surgery alone in 3, radiosurgery and WBRT in 2, and conservative management only in 6. Median overall survival was 3.0 months. Multivariate analysis showed ECOG performance status, Child-Pugh class, AFP level, number of brain lesions, and treatment modality were associated with survival (p < 0.05). When patients were stratified with four prognostic factors including ECOG performance status, Child-Pugh class, AFP level, and number of brain lesions, median survival time for patients with 0-1, 2, 3-4 risk factors were 5.8 months, 2.5 months and 0.6 months, respectively (p < 0.001). In conclusion, we can estimate the survival of patients by prognostic stratification, although overall prognosis of patients with brain metastases from hepatocellular carcinoma is poor.

Leptomeningeal metastasis from hepatocellular carcinoma with other unusual metastases: a case report

BACKGROUND

Leptomeningeal metastasis, which results from metastasis of tumors to the arachnoid and pia mater, can lead to the dissemination of tumor cells throughout the subarachnoid space via the cerebral spinal fluid, and frequently with a poor prognosis. The primary tumor in adults is most often breast cancer, lung cancer, or melanoma. Although leptomeningeal metastasis due to cholangiocarcinoma has been reported, to the best of our knowledge there is no cytologically confirmed report of leptomeningeal metastasis from hepatocellular carcinoma.

CASE PRESENTATION

We herein report a case of leptomeningeal metastasis from hepatocellular carcinoma in a 53-year-old woman with concomitant systemic metastases to the lung, bone, brain, kidney, adrenal gland, subcutaneous tissues, and abdominal pelvis. The neurological symptoms of the patient were relieved after treatment with methotrexate intra-cerebral spinal fluid chemotherapy concurrent with whole brain radiotherapy.

CONCLUSION

To our knowledge this is the first report of leptomeningeal metastasis from hepatocellular carcinoma confirmed by cytology. Treatment with methotrexate intra-cerebral spinal fluid chemotherapy concurrent with whole brain radiotherapy was effective.

Survival outcomes after whole brain radiation therapy and/or stereotactic radiosurgery for cancer patients with metastatic brain tumors in Korea: a systematic review

AIM

To compare survival outcomes after whole brain radiation therapy (WBRT), stereotactic radiosurgery (SRS), and WBRT plus SRS combination therapy in Korea, by performing a quantitative systematic review.

MATERIALS AND METHODS

We searched 10 electronic databases for reports on Korean patients treated with WBRT or SRS for brain metastases published prior to July 2010. Independent reviewers screened all articles and extracted the data. When a Kaplan-Meier survival curve was available, median survival time and standard errors were calculated. Summary estimates for the outcomes in each study were calculated using the inverse variance random-effects method.

RESULTS

Among a total of 2,761 studies, 20 studies with Korean patients (n=1,053) were identified. A combination of 12 studies (n=566) with WBRT outcomes showed a median survival time of 6.0 months (95%CI: 5.9-6.2), an overall survival rate of 5.6% (95%CI: 1-24), and a 6-month survival rate of 46.5% (95%CI: 37.2-56.1). For nine studies (n=412) on SRS, the median survival was 7.9 months (95%CI: 5.1-10.8), and the 6-month survival rate was 63.1% (95%CI: 49.8-74.8). In six studies (n=75) using WBRT plus SRS, the median survival was 10.7 months (95%CI: 4.7-16.6), and the overall and 6-month survival rates were 16.8% (95%CI: 6.2-38.2) and 85.7% (95%CI: 28.3-96.9), respectively.

CONCLUSIONS

WBRT plus SRS showed better 1-year survival outcome than of WBRT alone for Korean patients with metastatic brain tumors. However, the results of this analysis have to be interpreted cautiously, because the risk factors of patients were not adjusted in the included studies.

Brain metastasis from hepatocellular carcinoma: the role of surgery as a prognostic factor

Background

The incidence of brain metastasis from hepatocellular carcinoma (HCC) is expected to increase as a result of prolonged survival due to the recent advances in HCC treatment. However, there is no definite treatment strategy for brain metastasis from HCC mainly due to its rarity and dismal prognosis. To provide helpful recommendations in treatment of brain metastasis from HCC, the authors aimed to identify prognostic factors that influence survival rates with a review of the recently published data.

Methods

Thirty-three cases of brain metastasis, whose incidence was 0.65%, were selected from a total of 5015 HCC patients and reviewed retrospectively in terms of clinical and radiological features.

Results

Median overall survival time after diagnosis of brain metastasis was 10.4 weeks (95% confidence interval [CI], 5.1-15.7 weeks) with 1-, 6- and 12-month survival rates, of 79%, 24% and 6%, respectively. Median survival of the patients treated with surgical resection or surgical resection followed by whole-brain radiation therapy (WBRT) (25.3 weeks; range, 15.8-34.8 weeks) was longer than that of the patients treated with gamma knife surgery (GKS), WBRT, or GKS followed by WBRT (10.4 weeks; range, 7.5-13.3 weeks) as well as that of patients treated with only steroids (1 week; range, 0.0-3.3 weeks) (p < 0.001). Child-Pugh’s classification A group had a longer median survival time than Child-Pugh’s classification B or C group (14.4 weeks vs 8.4 weeks, p = 0.038). RPA class I & II group had also a longer median survival time than RPA class III group did (13.4 weeks vs 2.4 weeks, p = 0.001). Surgical resection (hazard ratio [HR] 0.23, 95% CI 0.08-0.66, p = 0.006) and good liver function at the time of brain metastasis (HR 0.25, 95% CI 0.09-0.69, p = 0.007) were found to be the powerful prognostic factors for favorable survival in the multivariate analysis. In addition, presence of intratumoral hemorrhage was a statistically significant prognostic factor for survival.

Conclusion

Although HCC patients with brain metastasis showed a very dismal prognosis, surgical intervention was shown to lead to relative prolongation of the survival time, especially in those with preserved hepatic function.

Stereotactic radiosurgery for brain metastases from hepatocellular carcinoma

The purpose of this study is to investigate the possible role of stereotactic radiosurgery (SRS) in the management of patients with brain metastases from hepatocellular carcinoma (HCC). Thirty-two consecutive patients with 80 brain metastases from HCC were treated with SRS. Twenty-eight (87.5 %) patients were male, and the mean age of the patients was 54 ± 12 years (range 22-73). Twenty-seven (84.4 %) patients were classified as RTOG RPA Class 2. The mean tumor volume was 6.14 ± 11.3 cm(3) (range 0.01-67.3). The mean marginal dose prescribed was 20.1 ± 3.6 Gy (range 10.0-25.0). The median overall survival time after SRS was 11.3 ± 5.8 weeks (95 % CI 0-22.7). A greater total volume of brain metastases (>14 cm(3)) was the only independent prognostic factor (HR = 2.419; 95 % CI 1.040-5.624; p = 0.040). The actuarial control rate of brain metastases was 51.3 % at 4 months after SRS. The prescribed marginal dose (>18 Gy) was significantly related with the actuarial tumor control (HR = 0.254; 95 % CI 0.089-0.725; p = 0.010). The prognosis of patients with brain metastases from HCC is dismal even with the modern technology of radiosurgery. The marginal dose prescribed should be reevaluated to improve upon the current poor local control rates.

Brain metastases from hepatocellular carcinoma: clinical features and prognostic factors

Background

Brain metastases (BM) from hepatocellular carcinoma (HCC) are extremely rare and are associated with a poor prognosis. The aim of this study was to define clinical outcome and prognostic determinants in patients with BM from HCC.

Methods

Between January 1994 and December 2009, all patients with HCC and BM treated in Sun Yat-sen University Cancer Center were retrospectively reviewed. Univariate and multivariate survival analyses were performed to identify possible prognostic factors.

Results

Forty-one patients were diagnosed with BM from HCC, an incidence of 0.47%. The median age at diagnosis of BM was 48.5 years. Thirty-three patients (80.5%) developed extracranial metastases at diagnosis of BM, and 30 patients (73.2%) had hepatitis B. Intracranial hemorrhage occurred in 19 patients (46.3%). BM were treated primarily either with whole brain radiation therapy (WBRT; 5 patients), stereotactic radiosurgery (SRS; 7 patients), or surgical resection (6 patients). The cause of death was systemic disease in 17 patients and neurological disease in 23. Patients in a high RPA (recursive partitioning analysis) class, treated with conservatively and without lung metastases, tended to die from neurological disease. Median survival after the diagnosis of BM was 3 months (95% confidence interval: 2.2-3.8 months). In multivariate analysis, the presence of extracranial metastases, a low RPA class and aggressive treatment, were positively associated with improved survival.

Conclusions

BM from HCC is rare and associated with an extremely poor prognosis. However, patients with a low RPA class may benefit from aggressive treatment. The clinical implication of extracranial metastases in HCC patients with BM needs further assessment.