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Katsumata R, Monobe Y, Akagi A, Yamatsuji T, Naomoto Y. Brain and Adrenal Metastasis From Unknown Primary Tumor: A Case Report. Cureus 2022; 14:e26438. [PMID: 35915686 PMCID: PMC9337777 DOI: 10.7759/cureus.26438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2022] [Indexed: 11/14/2022] Open
Abstract
The clinical management of brain metastasis (BM) and adrenal metastasis (AM) of cancer of unknown primary (CUP) can be challenging. A 73-year-old man presented to the hospital with sudden-onset hemiplegia. His laboratory data were normal, except for elevated levels of carcinoembryonic antigen (CEA) (33.8 ng/mL). Contrast-enhanced magnetic resonance imaging revealed a 2-cm mass with ring enhancement in the right parietal lobe and extensive vasogenic edema around the tumor. The lesion was diagnosed as BM; however, we could not detect the primary origin by fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT). Stereotactic radiotherapy was then administered, resulting in reduced tumor size and relief of symptoms. Follow-up after one year revealed an elevated CEA level (148.6 ng/mL) and remarkable fluorodeoxyglucose (FDG) uptake in the right adrenal gland, with an area of enhancement of 20 mm, on FDG-positron emission tomography computed tomography, with normal findings in other distant organs. He underwent adrenalectomy, and the adrenal tumor was diagnosed as a poorly differentiated adenocarcinoma likely of lung origin based on the histopathologic and immunohistochemistry findings of cytokeratin (CK) 7 (+), CK 20 (-), thyroid transcription factor-1 (TTF-1) (+), inhibin (-), napsin A (+), prostate-specific antigen (PSA) (-), caudal type homeobox 2 (CDX-2) (-), synaptophysin (-), and p40 (-). Metastatic tumors of unknown primary origin remain latent. Aggressive treatment of these lesions can be beneficial for symptom relief, diagnosis, and prolongation of survival.
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Pouyiourou M, Wohlfromm T, Kraft B, Hielscher T, Stichel D, von Deimling A, Delorme S, Endris V, Neumann O, Stenzinger A, Krämer A, Bochtler T. Local ablative treatment with surgery and/or radiotherapy in single-site and oligometastatic carcinoma of unknown primary. Eur J Cancer 2021; 157:179-189. [PMID: 34521064 DOI: 10.1016/j.ejca.2021.08.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 08/08/2021] [Accepted: 08/11/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Single-site carcinoma of unknown primary (CUP) is recognised as a distinct favourable subtype in the European Society of Medical Oncology (ESMO) classification. There is broad consensus that these patients are candidates for local ablative treatment strategies with surgery and/or radiotherapy, but data on their outcomes are scarce. PATIENTS AND METHODS In this study, we have addressed the prospects of cure and prognostic factors in a retrospective cohort of 63 patients who were eligible for local treatment at our centre. RESULTS Median event-free (EFS) and overall survival (OS) were 15.6 months and 52.5 months, respectively. Of 61 patients who received local treatment, 20 (32.8%) remained event-free over a median follow-up of 28 months. Baseline clinical parameters including affected organ, number, volume and histology of metastases had no significant impact on prognosis, whereas deleterious TP53 mutations and DNA copy number loss emerged as independent adverse risk factors with respect to EFS. Surgical treatment was associated with improved OS as compared to radiation-based therapy. CONCLUSION Our study advocates to pursue localised treatment with surgery and/or radiotherapy whenever feasible and implies that genetic parameters might additionally determine the clinical course of single-site CUP patients.
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Affiliation(s)
- Maria Pouyiourou
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ), Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Timothy Wohlfromm
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ), Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Bianca Kraft
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ), Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Thomas Hielscher
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Damian Stichel
- Institute of Neuropathology, University of Heidelberg, Heidelberg, Germany
| | | | - Stefan Delorme
- Division of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Volker Endris
- Institute of Pathology, University of Heidelberg, Heidelberg, Germany
| | - Olaf Neumann
- Institute of Pathology, University of Heidelberg, Heidelberg, Germany
| | | | - Alwin Krämer
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ), Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Tilmann Bochtler
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ), Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; Department of Medical Oncology, National Center for Tumor Diseases (NCT), University of Heidelberg, Heidelberg, Germany.
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3
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de Causans A, Carré A, Roux A, Tauziède-Espariat A, Ammari S, Dezamis E, Dhermain F, Reuzé S, Deutsch E, Oppenheim C, Varlet P, Pallud J, Edjlali M, Robert C. Development of a Machine Learning Classifier Based on Radiomic Features Extracted From Post-Contrast 3D T1-Weighted MR Images to Distinguish Glioblastoma From Solitary Brain Metastasis. Front Oncol 2021; 11:638262. [PMID: 34327133 PMCID: PMC8315001 DOI: 10.3389/fonc.2021.638262] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 06/17/2021] [Indexed: 01/06/2023] Open
Abstract
Objectives To differentiate Glioblastomas (GBM) and Brain Metastases (BM) using a radiomic features-based Machine Learning (ML) classifier trained from post-contrast three-dimensional T1-weighted (post-contrast 3DT1) MR imaging, and compare its performance in medical diagnosis versus human experts, on a testing cohort. Methods We enrolled 143 patients (71 GBM and 72 BM) in a retrospective bicentric study from January 2010 to May 2019 to train the classifier. Post-contrast 3DT1 MR images were performed on a 3-Tesla MR unit and 100 radiomic features were extracted. Selection and optimization of the Machine Learning (ML) classifier was performed using a nested cross-validation. Sensitivity, specificity, balanced accuracy, and area under the receiver operating characteristic curve (AUC) were calculated as performance metrics. The model final performance was cross-validated, then evaluated on a test set of 37 patients, and compared to human blind reading using a McNemar’s test. Results The ML classifier had a mean [95% confidence interval] sensitivity of 85% [77; 94], a specificity of 87% [78; 97], a balanced accuracy of 86% [80; 92], and an AUC of 92% [87; 97] with cross-validation. Sensitivity, specificity, balanced accuracy and AUC were equal to 75, 86, 80 and 85% on the test set. Sphericity 3D radiomic index highlighted the highest coefficient in the logistic regression model. There were no statistical significant differences observed between the performance of the classifier and the experts’ blinded examination. Conclusions The proposed diagnostic support system based on radiomic features extracted from post-contrast 3DT1 MR images helps in differentiating solitary BM from GBM with high diagnosis performance and generalizability.
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Affiliation(s)
- Alix de Causans
- Neuroradiology Department, Hôpital Sainte-Anne, GHU-Paris Psychiatrie et Neurosciences, Paris, France.,Université de Paris, Paris, France.,Inserm, UMR1266, IMA-Brain, Institut de Psychiatrie et Neurosciences, Paris, France
| | - Alexandre Carré
- Radiothérapie Moléculaire et Innovation Thérapeutique, INSERM UMR1030, Gustave Roussy Cancer Campus, Université Paris Saclay, Villejuif, France.,Département de Radiothérapie, Gustave Roussy, Université Paris Saclay, Villejuif, France
| | - Alexandre Roux
- Université de Paris, Paris, France.,Inserm, UMR1266, IMA-Brain, Institut de Psychiatrie et Neurosciences, Paris, France.,Service de Neurochirurgie, GHU Paris - Psychiatrie et Neurosciences - Hôpital Sainte-Anne, Paris, France
| | - Arnault Tauziède-Espariat
- Université de Paris, Paris, France.,Inserm, UMR1266, IMA-Brain, Institut de Psychiatrie et Neurosciences, Paris, France.,Service de Neuropathologie, GHU Paris - Psychiatrie et Neurosciences - Hôpital Sainte-Anne, Paris, France
| | - Samy Ammari
- Département de Radiologie, Gustave Roussy, Université Paris Saclay, Villejuif, France.,BioMaps UMR1281, Université Paris-Saclay, CNRS, INSERM, CEA, Orsay, France
| | - Edouard Dezamis
- Université de Paris, Paris, France.,Inserm, UMR1266, IMA-Brain, Institut de Psychiatrie et Neurosciences, Paris, France.,Service de Neurochirurgie, GHU Paris - Psychiatrie et Neurosciences - Hôpital Sainte-Anne, Paris, France
| | - Frederic Dhermain
- Radiothérapie Moléculaire et Innovation Thérapeutique, INSERM UMR1030, Gustave Roussy Cancer Campus, Université Paris Saclay, Villejuif, France.,Département de Radiothérapie, Gustave Roussy, Université Paris Saclay, Villejuif, France
| | - Sylvain Reuzé
- Radiothérapie Moléculaire et Innovation Thérapeutique, INSERM UMR1030, Gustave Roussy Cancer Campus, Université Paris Saclay, Villejuif, France.,Département de Radiothérapie, Gustave Roussy, Université Paris Saclay, Villejuif, France
| | - Eric Deutsch
- Radiothérapie Moléculaire et Innovation Thérapeutique, INSERM UMR1030, Gustave Roussy Cancer Campus, Université Paris Saclay, Villejuif, France.,Département de Radiothérapie, Gustave Roussy, Université Paris Saclay, Villejuif, France
| | - Catherine Oppenheim
- Neuroradiology Department, Hôpital Sainte-Anne, GHU-Paris Psychiatrie et Neurosciences, Paris, France.,Université de Paris, Paris, France.,Inserm, UMR1266, IMA-Brain, Institut de Psychiatrie et Neurosciences, Paris, France
| | | | - Johan Pallud
- Université de Paris, Paris, France.,Inserm, UMR1266, IMA-Brain, Institut de Psychiatrie et Neurosciences, Paris, France.,Service de Neurochirurgie, GHU Paris - Psychiatrie et Neurosciences - Hôpital Sainte-Anne, Paris, France
| | - Myriam Edjlali
- Neuroradiology Department, Hôpital Sainte-Anne, GHU-Paris Psychiatrie et Neurosciences, Paris, France.,Université de Paris, Paris, France.,Inserm, UMR1266, IMA-Brain, Institut de Psychiatrie et Neurosciences, Paris, France
| | - Charlotte Robert
- Radiothérapie Moléculaire et Innovation Thérapeutique, INSERM UMR1030, Gustave Roussy Cancer Campus, Université Paris Saclay, Villejuif, France.,Département de Radiothérapie, Gustave Roussy, Université Paris Saclay, Villejuif, France
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Brain Metastasis from Unknown Primary Tumour: Moving from Old Retrospective Studies to Clinical Trials on Targeted Agents. Cancers (Basel) 2020; 12:cancers12113350. [PMID: 33198246 PMCID: PMC7697886 DOI: 10.3390/cancers12113350] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/04/2020] [Accepted: 11/09/2020] [Indexed: 12/14/2022] Open
Abstract
Simple Summary Brain metastases (BMs) are the most common intracranial tumours in adults and occur up to 3–10 times more frequently than primary brain tumours. In up to 15% of patients with BM, the primary tumour cannot be identified. These cases are known as BM of cancer of unknown primary (CUP) (BM-CUP). The understanding of BM-CUP, despite its relative frequency and unfavourable outcome, is still incomplete and clear indications on management are missing. The aim of this review is to summarize current evidence on the diagnosis and treatment of BM-CUP. Abstract Brain metastases (BMs) are the most common intracranial tumours in adults and occur up to 3–10 times more frequently than primary brain tumours. BMs may be the cause of the neurological presenting symptoms in patients with otherwise previously undiagnosed cancer. In up to 15% of patients with BMs, the primary tumour cannot be identified. These cases are known as BM of cancer of unknown primary (CUP) (BM-CUP). CUP has an early and aggressive metastatic spread, poor response to chemotherapy, and poor prognosis. The pathogenesis of CUP seems to be characterized by a specific underlying pro-metastatic signature. The understanding of BM-CUP, despite its relative frequency and unfavourable outcome, is still incomplete and clear indications on management are missing. Advances in diagnostic tools, molecular characterization, and target therapy have shifted the paradigm in the approach to metastasis from CUP: while earlier studies stressed the importance of finding the primary tumour and deciding on treatment based on the primary diagnosis, most recent studies focus on the importance of identifying targetable molecular markers in the metastasis itself. The aim of this review is to summarize current evidence on BM-CUP, from the diagnosis and pathogenesis to the treatment, with a focus on available studies and ongoing clinical trials.
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Survival outcomes following craniotomy for intracranial metastases from an unknown primary. Int J Clin Oncol 2020; 25:1475-1482. [PMID: 32358736 PMCID: PMC7392948 DOI: 10.1007/s10147-020-01687-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 04/16/2020] [Indexed: 11/17/2022]
Abstract
Introduction Management of patients with intracranial metastases from an unknown primary tumor (CUP) varies compared to those with metastases of known primary tumor origin (CKP). The National Institute for Health and Care Excellence (NICE) recognizes the current lack of research to support the management of CUP patients with brain metastases. The primary aim was to compare survival outcomes of CKP and CUP patients undergoing early resection of intracranial metastases to understand the efficacy of surgery for patients with CUP. Methods A retrospective study was performed, wherein patients were identified using a pathology database. Data was collected from patient notes and trust information services. Surgically managed patients during a 10-year period aged over 18 years, with a histological diagnosis of intracranial metastasis, were included. Results 298 patients were identified, including 243 (82.0%) CKP patients and 55 (18.0%) CUP patients. Median survival for CKP patients was 9 months (95%CI 7.475–10.525); and 6 months for CUP patients (95%CI 4.263–7.737, p = 0.113). Cox regression analyses suggest absence of other metastases (p = 0.016), age (p = 0.005), and performance status (p = 0.001) were positive prognostic factors for improved survival in cases of CUP. The eventual determination of the primary malignancy did not affect overall survival for CUP patients. Conclusions There was no significant difference in overall survival between the two groups. Surgical management of patients with CUP brain metastases is an appropriate treatment option. Current diagnostic pathways specifying a thorough search for the primary tumor pre-operatively may not improve patient outcomes.
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Rassy E, Zanaty M, Azoury F, Pavlidis N. Advances in the management of brain metastases from cancer of unknown primary. Future Oncol 2019; 15:2759-2768. [PMID: 31385529 DOI: 10.2217/fon-2019-0108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Cancer of unknown primary accounts for 3-5% of all cancers for which an adequate investigation does not identify the primary tumor. The particular subset of brain metastasis in cancer of unknown primary (BMCUP) is a clinical challenge that lacks standardized diagnostic and therapeutic options. It is diagnosed predominantly in male patients in the sixth decade of age with complaints of headache, neurological dysfunction, cognitive and behavioral disturbances and seizures. The therapeutic approach to patients with BMCUP relies on local control and systemic treatment. Surgery or stereotactic radiosurgery and/or whole brain radiation therapy seems to be the cornerstone of the treatment approach to BMCUP. Systemic therapy remains essential as cancers of unknown primary are conceptually metastatic tumors. The benefits of chemotherapy were disappointing whereas those of targeted therapies and immune checkpoint inhibitors remain to be evaluated. In this Review, we address the advances in the diagnosis and treatment of BMCUP.
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Affiliation(s)
- Elie Rassy
- Department of Hematology-Oncology, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Mario Zanaty
- Department of Neurosurgical Surgery, University of Ioawa, Ioawa City, IA, USA
| | - Fares Azoury
- Department of Radiation Oncology, Hotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University, Lebanon
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Achrol AS, Rennert RC, Anders C, Soffietti R, Ahluwalia MS, Nayak L, Peters S, Arvold ND, Harsh GR, Steeg PS, Chang SD. Brain metastases. Nat Rev Dis Primers 2019; 5:5. [PMID: 30655533 DOI: 10.1038/s41572-018-0055-y] [Citation(s) in RCA: 499] [Impact Index Per Article: 99.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
An estimated 20% of all patients with cancer will develop brain metastases, with the majority of brain metastases occurring in those with lung, breast and colorectal cancers, melanoma or renal cell carcinoma. Brain metastases are thought to occur via seeding of circulating tumour cells into the brain microvasculature; within this unique microenvironment, tumour growth is promoted and the penetration of systemic medical therapies is limited. Development of brain metastases remains a substantial contributor to overall cancer mortality in patients with advanced-stage cancer because prognosis remains poor despite multimodal treatments and advances in systemic therapies, which include a combination of surgery, radiotherapy, chemotherapy, immunotherapy and targeted therapies. Thus, interest abounds in understanding the mechanisms that drive brain metastases so that they can be targeted with preventive therapeutic strategies and in understanding the molecular characteristics of brain metastases relative to the primary tumour so that they can inform targeted therapy selection. Increased molecular understanding of the disease will also drive continued development of novel immunotherapies and targeted therapies that have higher bioavailability beyond the blood-tumour barrier and drive advances in radiotherapies and minimally invasive surgical techniques. As these discoveries and innovations move from the realm of basic science to preclinical and clinical applications, future outcomes for patients with brain metastases are almost certain to improve.
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Affiliation(s)
- Achal Singh Achrol
- Department of Neurosurgery and Neurosciences, John Wayne Cancer Institute and Pacific Neuroscience Institute, Santa Monica, CA, USA.
| | - Robert C Rennert
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA.
| | - Carey Anders
- Division of Hematology/Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | | | - Manmeet S Ahluwalia
- Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
| | - Lakshmi Nayak
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Solange Peters
- Medical Oncology, Lausanne University Hospital, Lausanne, Switzerland
| | - Nils D Arvold
- Department of Radiation Oncology, St. Luke's Cancer Center, Duluth, MN, USA
| | - Griffith R Harsh
- Department of Neurosurgery, University of California-Davis, School of Medicine, Sacramento, CA, USA
| | - Patricia S Steeg
- Women's Malignancies Branch, Center for Cancer Research, National Cancer Center, Bethesda, MD, USA
| | - Steven D Chang
- Department of Neurosurgery, University of California-Davis, School of Medicine, Sacramento, CA, USA.
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8
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Füreder LM, Widhalm G, Gatterbauer B, Dieckmann K, Hainfellner JA, Bartsch R, Zielinski CC, Preusser M, Berghoff AS. Brain metastases as first manifestation of advanced cancer: exploratory analysis of 459 patients at a tertiary care center. Clin Exp Metastasis 2018; 35:727-738. [PMID: 30421093 PMCID: PMC6267666 DOI: 10.1007/s10585-018-9947-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 10/30/2018] [Indexed: 01/14/2023]
Abstract
Symptomatic brain metastases (BM) are a frequent and late complication in cancer patients. However, a subgroup of cancer patients presents with BM as the first symptom of metastatic cancer. Here we aimed to analyze the clinical course and prognostic factors of this particular BM patient population. Patients presenting with newly diagnosed BM without a history of metastatic cancer were identified from the Vienna Brain Metastasis Registry. Clinical characteristics and overall survival were retrieved by chart review. 459/2419 (19.0%) BM patients presented with BM as first symptom of advanced cancer. In 374/459 (81.5%) patients, an extracranial primary tumor, most commonly lung cancer, could be identified within 3 months after BM diagnosis. In 85/459 (18.5%) patients no extracranial primary tumor could be identified despite comprehensive diagnostic workup within the first 3 months after diagnosis of BM. Survival of patients with identified extracranial tumor differed only numerically from patients with cancer of unknown primary (CUP), however patients receiving targeted therapy after molecular workup showed significantly enhanced survival (20 months vs. 7 months; p = 0.003; log rank test). The GPA score showed a statistically significant association with median overall survival times in the CUP BM patients (class I: 46 months; class II: 7 months; class III: 4 months; class IV: 2 months; p < 0.001; log rank test). The GPA score has a strong prognostic value in patients with CUP BM and may be useful for patient stratification in the clinical setting. Comprehensive diagnostic workup including advanced imaging techniques and molecular tissue analyses appears to benefit patients by directing specific molecular targeted therapies.
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Affiliation(s)
- L M Füreder
- Clinical Division of Oncology, Comprehensive Cancer Center CNS Tumors Unit, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - G Widhalm
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - B Gatterbauer
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - K Dieckmann
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Radiotherapy, Medical University of Vienna, Vienna, Austria
| | - J A Hainfellner
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - R Bartsch
- Clinical Division of Oncology, Comprehensive Cancer Center CNS Tumors Unit, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - C C Zielinski
- Clinical Division of Oncology, Comprehensive Cancer Center CNS Tumors Unit, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - M Preusser
- Clinical Division of Oncology, Comprehensive Cancer Center CNS Tumors Unit, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - A S Berghoff
- Clinical Division of Oncology, Comprehensive Cancer Center CNS Tumors Unit, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.
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Koç ZP, Kara PÖ, Dağtekin A. Detection of unknown primary tumor in patients presented with brain metastasis by F-18 fluorodeoxyglucose positron emission tomography/computed tomography. CNS Oncol 2018; 7:CNS12. [PMID: 29708403 PMCID: PMC5977273 DOI: 10.2217/cns-2017-0018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Aim: F-18 fluorodeoxyglucose (FDG) PET/CT has several advantages in diagnosis of cancer of unknown primary with reported incremental diagnostic value. In this study, we evaluated the patients who were presented with multiple brain metastasis and unknown primary tumor. Materials & methods: 31 patients (17 males, 14 females; mean: 56.1 ± 14.22 years old) with diagnosis of brain metastasis according to histopathology and/or MRI were included into this retrospective study. Results: The patients presented with hypermetabolic (n = 17; mean SUVmax: 11.6 ± 6.9) or hypometabolic brain lesions with additional different metastatic sites in 13 patients (mean SUVmax: 9.03 ± 4.02). The primary tumor was determined by FDG PET/CT in 20/26 patients (77%) (lung [n = 6], primary brain [n = 9], renal cell carcinoma [n = 2], skin [n = 1], breast [n = 1] and neuroendocrine tumor [n = 1]). Conclusion: New generation multislice scanners may provide higher detection ratios. The detection rate of FDG PET/CT might be higher than previously reported according to this study.
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Affiliation(s)
- Zehra Pınar Koç
- Nuclear Medicine Department, Medical Faculty, Mersin University, Mersin, Turkey
| | - Pelin Özcan Kara
- Nuclear Medicine Department, Medical Faculty, Mersin University, Mersin, Turkey
| | - Ahmet Dağtekin
- Neurosurgery Department, Medical Faculty, Mersin University, Mersin, Turkey
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Stoyanov GS, Sarraf JS, Matev BK, Dzhenkov DL, Kitanova M, Iliev B, Ghenev P, Tonchev AB, Enchev Y, Adami F, De Carvalho LEW. A Comparative Review of Demographics, Incidence, and Epidemiology of Histologically Confirmed Intracranial Tumors in Brazil and Bulgaria. Cureus 2018; 10:e2203. [PMID: 29682433 PMCID: PMC5908715 DOI: 10.7759/cureus.2203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Intracranial tumors (ICTs) attract numerous scientific teams and tremendous financial resources worldwide. These lesions of the central nervous system (CNS) can be both benign and malignant in biological behavior as well as local or metastatic in origin. We compared data from two studies on primary and metastatic ICTs from Brazil and Bulgaria, based on histopathologically confirmed ICTs from tertiary health centers. Primary ICTs significantly outweigh the frequency of metastatic ICTs. Primary ICTs represent 86.45% in Brazil and 69.17% in Bulgaria, with around 60% of their totals being malignant. There is a statistical dominance of tumors from the neuroepithelial origin, with the most common entry being glioblastoma multiforme. The second-most common primary ICT group comprises tumors of meningeal origin. Metastatic ICTs show great variance; 13.55% in Brazil and 31.38% in Bulgaria of all ICT cases being attributed to them. However, metastatic ICTs are even a more diverse group than neuroepithelial tumors, with the majority of this group comprising metastatic colorectal adenocarcinoma (almost exclusively in males), metastatic breast adenocarcinoma in females, metastatic pulmonary carcinomas (primarily from the non-small cell group with a male predominance), and metastatic melanoma with an even gender ratio.
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Affiliation(s)
- George S Stoyanov
- Department of General and Clinical Pathology, Forensic Medicine and Deontology, Medical University - Varna "prof. Dr. Paraskev Stoyanov", Varna, Bulgaria
| | - Jonathan S Sarraf
- Genetic and Molecular Biology, Universidade Federal Do Pará, Belém, Pará, Brazil
| | - Boyko K Matev
- Student, Faculty of Medicine, Medical University - Varna "Prof. Dr. Paraskev Stoyanov", Varna, Bulgaria
| | - Deyan L Dzhenkov
- Department of General and Clinical Pathology, Forensic Medicine and Deontology, Faculty of Medicine, Medical University - Varna "Prof. Dr. Paraskev Stoyanov", Varna, Bulgaria
| | - Martina Kitanova
- Department of General and Clinical Pathology, Forensic Medicine and Deontology, Faculty of Medicine, Medical University - Varna "Prof. Dr. Paraskev Stoyanov", Varna, Bulgaria
| | - Bogomil Iliev
- Department of Neurosurgery and Ent Diseases, Division of Neurosurgery, Faculty of Medicine, Medical University - Varna "Prof. Dr. Paraskev Stoyanov", Varna, Bulgaria
| | - Peter Ghenev
- Department of General and Clinical Pathology, Forensic Medicine and Deontology, Faculty of Medicine, Medical University - Varna "Prof. Dr. Paraskev Stoyanov", Varna, Bulgaria
| | - Anton B Tonchev
- Department of Anatomy and Cell Biology, Faculty of Medicine, Medical University - Varna "Prof. Dr. Paraskev Stoyanov", Varna, Bulgaria
| | - Yavor Enchev
- Department of Neurosurgery and Ent Diseases, Division of Neurosurgery, Faculty of Medicine, Medical University - Varna "Prof. Dr. Paraskev Stoyanov", Varna, Bulgaria
| | - Fernando Adami
- Laboratory of Epidemiology and Data Analysis, Faculdadede Medicina Do Abc, Santo André, São Paulo, Brazil
| | - Luis Eduardo W De Carvalho
- Laboratory of Epidemiology and Data Analysis, Faculdadede Medicina Do Abc, Santo André, São Paulo, Brazil
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Huang WT, Lu NM, Hsu WY, Chang SE, Atkins A, Mei R, Javey M. CSF-ctDNA SMSEQ Analysis to Tailor the Treatment of a Patient with Brain Metastases: A Case Report. Case Rep Oncol 2018. [PMID: 29515413 PMCID: PMC5836181 DOI: 10.1159/000486568] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Brain metastases are the most common neurological complications of adult cancers, accounting for more than half of brain tumors. The incidence of brain metastases may be increasing due to improved detection of small lesions by advanced imaging technologies. Given the fast evolution of targeted and immunotherapy regimens, it is essential to serially assess brain malignancies during the disease course for disease monitoring and tailoring of the therapeutic management. For such serial and repetitive assessment, cerebrospinal fluid (CSF) could be the biological fluid of choice to supplement cytology examination for the presence or absence of CNS malignancy, as well as provide extensive information on tumor mutational profile for personalization of treatment. The case described here emphasizes the importance of CSF-ctDNA analysis with the CellMax SMSEQ technology that led to treatment adjustment resulting in clinical remission of the patient.
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Affiliation(s)
- Wen-Tsung Huang
- aDivision of Hematology-Oncology, Department of Internal Medicine, Chi Mei Medical Center, Liouying, Tainan City, Taiwan
| | - Na-Mi Lu
- bDepartment of Pathology, Chi Mei Medical Center, Liouying, Tainan City, Taiwan
| | - Wen-Yuan Hsu
- cDepartment of Medical Imaging, Chi Mei Medical Center, Liouying, Tainan City, Taiwan
| | | | | | - Rui Mei
- eCellMax Inc., Sunnyvale, California, USA
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12
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Stoyanov GS, Dzhenkov DL, Kitanova M, Ghenev P, Tonchev AB. Demographics and Incidence of Histologically Confirmed Intracranial Tumors: A Five-year, Two-center Prospective Study. Cureus 2017; 9:e1476. [PMID: 28944115 PMCID: PMC5602374 DOI: 10.7759/cureus.1476] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction Intracranial tumors (ICTs) are a diverse group of malignancies that pose an immediate threat to patients' lives, no matter their local or metastatic origin, benign or malignant nature. These lesions have severe clinical courses and need to be diagnosed and treated as soon as possible, with pathological verification being the pivotal moment in the process of determining curative modalities. Aim The aim of this study was to compare the incidence of histologically confirmed ICTs in Eastern Bulgaria, based on their type (primary, metastatic, and non-volume occupying lesions (NVOL)), their respective subtypes, and incidence in a descriptive manner. Materials and Methods For a period of five full calendar years (January 1st, 2012 – December 31st, 2016), all histologically confirmed cases of intracranial tumors were prospectively collected from two individual tertiary healthcare institutions. The cases were then statistically analyzed in a descriptive manner, and incidences of primary, metastatic, and NVOL were compared with regards to their specific origins, types, and subtypes. Metastatic tumors were further segregated relative to their intracranial metastatic location. Results The total number of individual ICTs registered in the set timeframe was 822. Primary ICTs represented a total of 66.12% of the histologically confirmed cases, with the most common entries being tumors from a glial and meningeal origin, 30.90% were histologically confirmed as metastatic ICTs, from which the most common entries were of pulmonary origin, and the other 2.94% were NVOL. On behalf of their intracranial metastatic location, metastatic tumors were located predominantly in the supratentorial region, represented as a total of 87.80%, while the other 12.20% were located in the subtentorial region. Based on the descriptive analysis, the annual incidence per 100,000 capita of all ICTs is 9.12, comprised of 6.03 per 100,000 for primary ICTs, 2.82 per 100,000 for metastatic ICTs, and 0.27 per 100,000 for NVOL. The annual incidence of the most commonly diagnosed primary ICTs per 100,000 is 2.36 for meningioma, 2.03 for glioblastoma, and 0.48 for pituitary adenoma. The annual incidence of the most commonly diagnosed metastatic ICTs per 100,000 is 1.32 for lung cancer metastases, 0.28 for gastrointestinal tract (GIT) metastases, 0.22 for melanoma, and 0.17 for breast cancer metastases. Conclusion Based on our results, primary ICTs are operated and biopsied more than two times as much as metastatic ICTs and only a small fraction of neurosurgical interventions are undertaken due to NVOL. Metastatic ICTs are predominantly supratentorial with no evidence of a tumor predominantly metastasizing in the subtentorial region. The demographics reported in the study establish some aspects of age and gender preferences, as well as the annual incidence per 100,000 for the most commonly diagnosed types of ICTs in our population.
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Affiliation(s)
- George S Stoyanov
- Department of Physiology and Pathophysiology, Division of Pathophysiology, Faculty of Medicine, Medical University - Varna "Prof. Dr. Paraskev Stoyanov", Varna, Bulgaria
| | - Deyan L Dzhenkov
- Department of General and Clinical Pathology, Forensic Medicine and Deontology, Faculty of Medicine, Medical University - Varna "Prof. Dr. Paraskev Stoyanov", Varna, Bulgaria
| | - Martina Kitanova
- Department of General and Clinical Pathology, Forensic Medicine and Deontology, Faculty of Medicine, Medical University - Varna "Prof. Dr. Paraskev Stoyanov", Varna, Bulgaria
| | - Peter Ghenev
- Department of General and Clinical Pathology, Forensic Medicine and Deontology, Faculty of Medicine, Medical University - Varna "Prof. Dr. Paraskev Stoyanov", Varna, Bulgaria
| | - Anton B Tonchev
- Department of Anatomy and Cell Biology, Faculty of Medicine, Medical University - Varna "Prof. Dr. Paraskev Stoyanov", Varna, Bulgaria
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13
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Han HJ, Chang WS, Jung HH, Park YG, Kim HY, Chang JH. Optimal Treatment Decision for Brain Metastases of Unknown Primary Origin: The Role and Timing of Radiosurgery. Brain Tumor Res Treat 2016; 4:107-110. [PMID: 27867920 PMCID: PMC5114180 DOI: 10.14791/btrt.2016.4.2.107] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 09/27/2016] [Accepted: 09/29/2016] [Indexed: 11/20/2022] Open
Abstract
Background Up to 15% of all patients with brain metastases have no clearly detected primary site despite intensive evaluation, and this incidence has decreased with the use of improved imaging technology. Radiosurgery has been evaluated as one of the treatment modality for patients with limited brain metastases. In this study, we evaluated the effectiveness of radiosurgery for brain metastases from unknown primary tumors. Methods We retrospectively evaluated 540 patients who underwent gamma knife radiosurgery (GKRS) for brain metastases radiologically diagnosed between August 1992 and September 2007 in our institution. First, the brain metastases were grouped into metachronous, synchronous, and precocious presentations according to the timing of diagnosis of the brain metastases. Then, synchronous and precocious brain metastases were further grouped into 1) unknown primary; 2) delayed known primary; and 3) synchronous metastases according to the timing of diagnosis of the primary origin. We analyzed the survival time and time to new brain metastasis in each group. Results Of the 540 patients, 29 (5.4%) presented precocious or synchronous metastases (34 GKRS procedures for 174 lesions). The primary tumor was not found even after intensive and repeated systemic evaluation in 10 patients (unknown primary, 34.5%); found after 8 months in 3 patients (delayed known primary, 1.2%); and diagnosed at the same time as the brain metastases in 16 patients (synchronous metastasis, 55.2%). No statistically significant differences in survival time and time to new brain metastasis were found among the three groups. Conclusion Identification of a primary tumor before GKRS did not affect the patient outcomes. If other possible differential diagnoses were completely excluded, early GKRS can be an effective treatment option for brain metastases from unknown primary tumor.
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Affiliation(s)
- Hyun Jin Han
- Department of Neurosurgery, Yonsei University Health System, Seoul, Korea
| | - Won Seok Chang
- Department of Neurosurgery, Yonsei University Health System, Seoul, Korea.; Gamma Knife Center, Yonsei University Health System, Seoul, Korea
| | - Hyun Ho Jung
- Department of Neurosurgery, Yonsei University Health System, Seoul, Korea.; Gamma Knife Center, Yonsei University Health System, Seoul, Korea
| | - Yong Gou Park
- Department of Neurosurgery, Yonsei University Health System, Seoul, Korea.; Gamma Knife Center, Yonsei University Health System, Seoul, Korea
| | - Hae Yu Kim
- Department of Neurosurgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jong Hee Chang
- Department of Neurosurgery, Yonsei University Health System, Seoul, Korea.; Brain Tumor Center, Yonsei University Health System, Seoul, Korea.; Gamma Knife Center, Yonsei University Health System, Seoul, Korea
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14
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Abstract
Brain metastases are an attractive target for radiosurgery. Over a period of 6 years, 400 patients with brain metastases have been treated with radiosurgery. Of these patients, 61% had solitary brain metastases and 39% had multiple brain metastases. Local control was achieved in 90% and improvement of severe neurological symptoms in 76%. The median survival time was 8 months. The significant prognostic factors for survival in patients with solitary brain metastases were age, Karnofsky performance status, severity of symptoms, extent of progressive malignant disease outside the brain, histology, interval between diagnosis of primary tumor and brain metastasis, and minimum applied dosage. The significant prognostic factors in patients with multiple brain metastases were sex, Karnofsky performance status and presence of progressive disease outside the brain.
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Affiliation(s)
- Gabriela Simonová
- Department of Stereotactic and Radiation Neurosurgery, Hospital Na Homolce, Prague, Czech Republic.
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15
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Jin J, Zhou X, Liang X, Huang R, Chu Z, Jiang J, Zhan Q. Brain metastases as the first symptom of lung cancer: a clinical study from an Asian medical center. J Cancer Res Clin Oncol 2012; 139:403-8. [PMID: 23124140 DOI: 10.1007/s00432-012-1344-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Accepted: 10/22/2012] [Indexed: 11/25/2022]
Affiliation(s)
- Jia Jin
- Department of Oncology, Huashan Hospital, Fudan University, 12 Middle Wulumuqi Road, Shanghai 200040, China
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16
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McNally ME, Carson W. Occult Breast Cancer Presenting as Leptomeningeal Carcinomatosis. World J Oncol 2012; 3:73-77. [PMID: 29147283 PMCID: PMC5649892 DOI: 10.4021/wjon408w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2011] [Indexed: 12/31/2022] Open
Abstract
Leptomeningeal carcinomatosis (LC) is a rare and devastating metastatic manifestation of both liquid and solid tumors consisting of dissemination of malignant cells with invasion into the meninges. Few options exist in most clinical situations, especially when LC is the presenting sign of occult malignancy. The prognosis is often poor with limited survival. Aims of palliation must be considered the primary goal for most patients. We report a case in which occult metastatic breast cancer presented with neurological symptoms from LC. We discuss diagnosing the primary malignancy when LC is the presenting manifestation as well as treatment, both palliative and cytoreductive. We also focus on those patients with breast cancer that are at highest risk of developing LC.
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Affiliation(s)
- Megan E. McNally
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, USA
| | - William Carson
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, USA
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17
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Affiliation(s)
- R Soffietti
- Division of Neuro-oncology, University and San Giovanni Battista Hospital, Turin, Italy.
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18
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Jin J, Zhou X, Liang X, Huang R, Chu Z, Jiang J, Zhan Q. A study of patients with brain metastases as the initial manifestation of their systemic cancer in a Chinese population. J Neurooncol 2010; 103:649-55. [PMID: 20978821 DOI: 10.1007/s11060-010-0440-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2010] [Accepted: 10/12/2010] [Indexed: 11/24/2022]
Abstract
To investigate the clinical characteristics of patients with brain metastases as the initial manifestation of their systemic cancer in a Chinese population, a retrospective study of 254 such patients admitted to Huashan Hospital, Fudan University, Shanghai, China between January 1, 2003 and December 30, 2008 was performed. Data were collected to determine the features of this group (i.e., manifesting signs and symptoms, imaging studies, extracerebral metastases, primary tumor sites, initial diagnosis, and survival data). Common symptoms included headache and motor impairment. The distribution of brain metastases paralleled blood flow, and the majority of brain metastases were located in the cerebral hemispheres. Magnetic resonance imaging (MRI) was more sensitive than computed tomography (CT) for confirming presence of brain lesions. This distinct clinical entity exhibited high rates of misdiagnosis at initial presentation. Pathology varied, and adenocarcinomas were most commonly observed. Underlying primary tumors were identified in 84.2% of patients, most often located in lung (71.7%), followed by digestive tract. Chest CT had high yield. Sixty-two patients presented with silent extracerebral metastases at initial presentation. Median survival time was 15 months (95% confidence interval, 12.2-17.8 months). Survival rates for 1, 2, and 5 years were 59.2%, 23.2%, and 15.1%, respectively. Contrast-enhanced MRI had high yield for detection of brain metastases. Adenocarcinoma was the most common histologic type. Given the high frequency of primary lung tumors and the sensitivity of chest CT, chest CT should be a part of the initial screen of primary site with brain metastases as the initial manifestation. Metastatic dissemination of malignancy to the brain as the initial manifestation is generally associated with dismal prognosis, with the exception of a minority who experience long survival.
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Affiliation(s)
- Jia Jin
- Department of Oncology, Huashan Hospital, Fudan University, 12 Middle Wulumuqi Road, Shanghai 200040, China
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19
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Small cell carcinoma originating from the cavernous sinus. Acta Neurochir (Wien) 2010; 152:493-500. [PMID: 19434364 DOI: 10.1007/s00701-009-0389-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2008] [Accepted: 04/21/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND We report a rare case of small cell carcinoma originating from the right cavernous sinus in a 55-year-old male. The patient had sudden onset of right abducens palsy following right oculomotor palsy. METHODS Post-contrast T1-weighted MRI revealed a mass lesion of 3-cm maximum size occupying the right cavernous sinus and extending to the right middle cranial fossa. After biopsy via the frontozygomatic approach, one radiosurgery treatment was followed by four cycles of chemotherapy (cisplatin together with VP-16 therapy), after which the lesion diminished dramatically in size. RESULTS Complete remission has currently been achieved. The patient recovered from the extraocular muscle paresis and returned to his previous work. Although it is considered possible that small cell carcinoma can occur wherever neuroendocrine cells exist, a lesion originating in the cranium is extremely rare. To the best of our knowledge, this is the first report of small cell carcinoma of intracranial origin.
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20
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Niranjan A, Kano H, Khan A, Kim IY, Kondziolka D, Flickinger JC, Lunsford LD. Radiosurgery for brain metastases from unknown primary cancers. Int J Radiat Oncol Biol Phys 2010; 77:1457-62. [PMID: 20056342 DOI: 10.1016/j.ijrobp.2009.07.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Revised: 06/17/2009] [Accepted: 07/06/2009] [Indexed: 11/29/2022]
Abstract
PURPOSE We evaluated the role of Gamma Knife stereotactic radiosurgery in the multidisciplinary management of brain metastases from an undiagnosed primary cancer. METHODS AND MATERIALS Twenty-nine patients who had solitary or multiple brain metastases without a detectable primary site underwent stereotactic radiosurgery between January 1990 and March 2007 at the University of Pittsburgh. The median patient age was 61.7 years (range, 37.9-78.7 years). The median target volume was 1.0 cc (range, 0.02-23.6 cc), and the median margin radiosurgical dose was 16 Gy (range, 20-70 Gy). RESULTS After radiosurgery, the local tumor control rate was 88.5%. Twenty four patients died and 5 patients were living at the time of this analysis. The overall median survival was 12 months. Actuarial survival rates from stereotactic radiosurgery at 1 and 2 years were 57.2% and 36.8%, respectively. Factors associated with poor progression-free survival included large tumor volume (3 cc or more) and brainstem tumor location. CONCLUSIONS Radiosurgery is an effective and safe minimally invasive option for patients with brain metastases from an unknown primary site.
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Affiliation(s)
- Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh, UPMC Presbyterian, Pittsburgh, Pennsylvania 15213, USA.
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21
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Abstract
Patients with carcinoma of unknown primary site are heterogeneous with respect to clinical and pathologic features. Within this diverse group, specific clinical and/or pathologic features can be used to define several subsets with favorable prognoses. Specific subsets include women with peritoneal carcinomatosis, women with isolated axillary lymph node metastases, adenocarcinoma presenting as a single metastatic lesion, young men with features of extragonadal germ cell tumor, squamous carcinoma involving cervical or inguinal lymph nodes, and neuroendocrine carcinoma. Prospective identification of patients in these favorable subgroups allows the most effective treatment to be selected. This review summarizes current recommendations for the evaluation and treatment of patients in each of these favorable prognostic subsets.
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22
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Krämer A, Hübner G, Schneeweiss A, Folprecht G, Neben K. Carcinoma of Unknown Primary - an Orphan Disease? ACTA ACUST UNITED AC 2008; 3:164-170. [PMID: 20824034 DOI: 10.1159/000136001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Carcinoma of unknown primary (CUP) is an intriguing clinical finding that is defined as biopsy-proven metastasis from a malignancy in the absence of an identifiable primary site after a complete clinical work-up. CUP is a relatively common clinical entity, accounting for approximately 3-5% of all cancer diagnoses, and consists of a heterogeneous group of tumors that have acquired the capacity to metastasize before the development of a clinically evident primary lesion. Notable advances have been made over the past years in the treatment of well-defined clinical subgroups of CUP, such as women with peritoneal carcinomatosis and young adults with poorly differentiated carcinomas of midline distribution, but for the majority of patients, the prognosis still remains poor. In this review, we highlight recent advances in the diagnosis and treatment of patients with CUP syndrome, and emphasize the importance of identifying several favorable subsets of CUP, amenable to specific treatment options. In addition, we will point out novel diagnostic and therapeutic approaches which will hopefully improve both our understanding and the prognosis of this more or less neglected disease.
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Affiliation(s)
- Alwin Krämer
- Klinische Kooperationseinheit für Molekulare Hämatologie und Onkologie des Deutsches Krebsforschungszentrums und der Medizinischen Klinik und Poliklinik V der Universität Heidelberg, Germany
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23
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Guillamo JS, Emery E, Busson A, Lechapt-Zalcman E, Constans JM, Defer GL. [Current management of brain metastases]. Rev Neurol (Paris) 2008; 164:560-8. [PMID: 18565355 DOI: 10.1016/j.neurol.2008.03.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2007] [Accepted: 03/20/2008] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Cerebral metastases occur in 15 to 20% of cancers and their incidence is increasing. The majority occur at an advanced stage of the disease, but metastasis may be the inaugural sign of cancer. The aim of treatments, which are often palliative, is to preserve the neurological status of the patient with the best quality of life. STATE OF ART Corticosteroids are widely used for symptomatic palliation, requiring close monitoring and regular dose adaptation. Antiepileptic drugs should be given only for patients who have had a seizure. In case of multiple cerebral metastases occurring at an advanced stage of the disease, whole brain radiation is the most effective therapy for rapid symptom control. However, radiotherapy moderately improves overall survival, which often depends on the progression of disseminated systemic disease. On the contrary, surgery is indicated in case of a solitary metastasis, particularly when the patient is young (less than 65 years), with good general status (Karnofsky greater than 70), and when the systemic disease is under control. Radiosurgery offers an attractive alternative for these patients with good prognostic factors and a small number of cerebral metastases (< or = 4). PERSPECTIVES Chemotherapy, considered in the past as not effective, is taking on a more important place in patients with multiple nonthreatening metastases from chemosensitive cancers (breast, testes...). Radiosurgery and whole brain radiotherapy are complementary techniques. Their respective role in the management of multiple metastases (< 4) remains to be further investigated. CONCLUSIONS Therapeutic options are increasingly effective to improve the functional prognosis of patients with cerebral metastases. Ideally, a multidisciplinary assessment offers the best choice of therapeutic modalities.
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Affiliation(s)
- J-S Guillamo
- Service de neurologie Dejerine, centre hospitalo-universitaire de Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex, France.
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Dagnew E, Langford LA, Lang FF, DeMonte F. Papillary Tumors of the Pineal Region: Case Report. Neurosurgery 2007; 60:E953-5; discussion E953-5. [PMID: 17460510 DOI: 10.1227/01.neu.0000255443.44365.77] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
The pineal region is a rare intracranial site for metastasis. We report three patients initially considered to have metastatic papillary adenocarcinoma to the pineal region. On review, these papillary, keratin-positive neoplasms meet the criteria for papillary tumor of the pineal region (PTPR).
CLINICAL PRESENTATION
These neoplasms occurred in three women (age range, 37–55 yr). Imaging studies demonstrated well-circumscribed lesions in the pineal region. All patients presented with obstructive hydrocephalus and symptoms attributable to hydrocephalus and tectal compression.
INTERVENTION
All three patients underwent near total microsurgical resection of the pineal region neoplasm, followed by adjuvant radiotherapy. The two patients with long-term follow-up (56–60 mo) have remained clinically stable without evidence of local or distant recurrence. The first two patients were initially diagnosed as having papillary metastatic carcinoma of unknown origin. The third patient was treated after the recent description of PTPR and met the histopathological diagnostic criteria. Retrospective pathological review of the previous two patients resulted in designation as PTPR.
CONCLUSION
The morphological features of the tumors in our series, along with the clinical presentations, are similar to those in the original description of the PTPR. Our findings agree with the original hypothesis that the cells composing the PTPR are similar to ependymal cells of the subcommissural organ, thus furthering the hypothesis that the PTPR derives from a specialized ependymocyte associated with the subcommissural organ. The two patients with long-term follow-up (56–60 mo) have remained clinically stable without evidence of local or distant recurrence.
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D'Ambrosio AL, Agazzi S. Prognosis in patients presenting with brain metastasis from an undiagnosed primary tumor. Neurosurg Focus 2007; 22:E7. [PMID: 17608360 DOI: 10.3171/foc.2007.22.3.8] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The aim of this study was to test the validity of the hypothesis that patients in whom brain metastasis is the first indication of an undiagnosed primary tumor have a better chance of survival than similar patients with a known primary lesion. METHODS Between January 1983 and December 1998, 342 patients with computed tomography-diagnosed brain metastases were treated at a single institution. Information on potential prognostic factors, including primary diagnosis status, was collected retrospectively. Univariate and multivariate analyses were performed to identify prognostic factors related to survival. Survival was not statistically different between patients with an undiagnosed primary (UDP) lesion and those with a diagnosed primary (DP) tumor (6 and 4.5 months, respectively; p = 0.097). In the UDP group (122 patients [36%]), survival was not affected by the eventual identification of the primary disease (p = 0.905). The median survival for the entire population was 5.2 months, with 1-, 2-, and 3-year survival rates of 25, 11, and 4%, respectively. Prognostic factors for the overall population included treatment (p < 0.0001), an age less than 65 years (p = 0.004), discharge status (p < 0.001), absence of systemic metastasis (p = 0.036), and asymptomatic cerebral metastasis (p = 0.05). CONCLUSIONS Treatment modality was the most significant independent variable affecting survival in patients with brain metastases. Eventual identification of a primary tumor does not affect overall survival; therefore, delaying therapeutic intervention in pursuit of a primary diagnosis may not be appropriate. Data in this study failed to demonstrate a statistically significant difference in survival between patients with UDP and those with DP lesions, on first presenting with brain metastases.
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Affiliation(s)
- Anthony L D'Ambrosio
- Department of Neurological Surgery, University of South Florida, Tampa, Florida 33606, USA.
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26
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Naggara O, Brami-Zylberberg F, Rodrigo S, Raynal M, Meary E, Godon-Hardy S, Oppenheim C, Meder JF. Imagerie des métastases intracrâniennes chez l’adulte. ACTA ACUST UNITED AC 2006; 87:792-806. [PMID: 16778748 DOI: 10.1016/s0221-0363(06)74088-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Intracranial metastases account for up to 35% of intracranial tumors in adult. They can involve any part of the central nervous system: brain, meninges and cranial nerves. Any systemic tumor can metastasize to the brain; the most common primaries include lung, breast and melanoma. Imaging plays a major role in the evaluation and management of patients with metastatic brain tumors. This article discusses optimal CT and MR imaging protocols and describes imaging features and distinguishing characteristics of cerebral and meningeal metastases.
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Affiliation(s)
- O Naggara
- Département d'Imagerie morphologique et fonctionnelle, Centre Hospitalier Sainte-Anne, 1, rue Cabanis, 75674 Paris Cedex 14.
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Soffietti R, Costanza A, Laguzzi E, Nobile M, Rudà R. Radiotherapy and chemotherapy of brain metastases. J Neurooncol 2005; 75:31-42. [PMID: 16215814 DOI: 10.1007/s11060-004-8096-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The authors have reviewed the results, the indications and the controversies regarding radiotherapy and chemotherapy of patients with newly diagnosed and recurrent brain metastases. Whole-brain radiotherapy, radiosurgery, hypofractionated stereotactic radiotherapy, brachytherapy and chemotherapy are the available options. New radiosensitizers and cytotoxic or cytostatic agents are being investigated. Adjuvant whole brain radiotherapy, either after surgery or radiosurgery, and prophylactic cranial irradiation in small-cell lung cancer are discussed, taking into account local control, survival, and risk of late neurotoxicity. Increasingly, the different treatments are tailored to the different prognostic subgroups, as defined by Radiation Therapy Oncology Group RPA Classes.
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Affiliation(s)
- R Soffietti
- Neuro-Oncology Service, Department of Neuroscience, University and Azienda Ospedaliera San Giovanni Battista, Torino, Italy.
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28
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Polyzoidis KS, Miliaras G, Pavlidis N. Brain metastasis of unknown primary: A diagnostic and therapeutic dilemma. Cancer Treat Rev 2005; 31:247-55. [PMID: 15913895 DOI: 10.1016/j.ctrv.2005.03.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The diagnosis of a brain metastasis is usually made during the routine follow up examinations of patients with known cancer, who are under the care of oncology departments. The involvement of the neurosurgeon depends on the philosophy and referral patterns of each oncology group. Patients with brain metastases of unknown primary (BMUP) are much more likely to seek the help of a neurosurgeon or a neurologist before contacting an oncologist, because the presenting clinical features originate from the brain. BMUPs are almost equal in numbers to brain primaries and differ from regular cerebral metastases regarding their site of origin, which will remain unknown in about 50% despite vigorous investigation. The clinical picture is similar to that of primary brain tumours but they seem to show different areas of predilection in the brain parenchyma. By reviewing the literature we are presenting the epidemiology, clinical presentation, diagnostic workup and treatment plan for this group of patients.
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Affiliation(s)
- Konstantinos S Polyzoidis
- Department of Neurosurgery, Medical School, University of Ioannina, P.O. Box 1186, Post code 45110, Ioannina, Greece.
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Abstract
When should surgery be used? First, when there is a need to establish the diagnosis of metastatic cancer, particularly in patients who have no known primary lesion. Second, as an effective therapy in patients who have a single brain metastasis, symptomatic or recurrent metastases, or when a metastasis threatens hydrocephalus if treated with radiation alone. Surgery is probably more effective in relieving symptoms from metastases than other treatments,although formal proof of this is lacking. Stereotactic radiosurgery can replace resection when the metastases are smaller than 3 cm and symptoms can be controlled with an acceptable steroid dose. Location of larger lesions in the posterior fossa is a relative contraindication to radiosurgery. The best candidates for resection and radiosurgery are those who have good systemic control of the primary disease; older age is a relative contraindication to resection. Aggressive treatment of oligometastatic brain disease probably is underused in current U.S. practice.
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Affiliation(s)
- Fred G Barker
- Department of Surgery (Neurosurgery), Harvard Medical School, Boston, MA, USA.
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Ghosh L, Dahut W, Kakar S, Posadas EM, Torres CG, Cancel-Santiago R, Ghosh BC. Management of patients with metastatic cancer of unknown primary. Curr Probl Surg 2005; 42:12-66. [PMID: 15711508 DOI: 10.1067/j.cpsurg.2004.10.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Luna Ghosh
- Pathology, State University of New York-Brooklyn, Brooklyn, NY, USA
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Taweevisit M, Isarakul P, Chaipipat M, Keetacheeva K, Wattanasirmkit V, Shuangshoti S. Cytokeratin 7 and 20 as immunohistochemical markers in identification of primary tumors in craniospinal metastases: do they have a significant role? Neuropathology 2004; 23:271-4. [PMID: 14719541 DOI: 10.1046/j.1440-1789.2003.00511.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cytokeratin (CK)7 and CK20, the low molecular weight cytokeratins, have been found to have a benefit in the differential diagnosis of some epithelial neoplasms. In the present study, the actual role of these markers in the search of primary tumors in 32 patients with craniospinal metastasis of an unknown primary site at presentation, is evaluated. A series of 36 patients with a known primary tumor were presented for comparison. In the first group, two CK7 and CK20 expression profiles were observed; 87% of metastatic tumors were CK7+/CK20- and 13% CK7-/CK20-. The lung was the major source (82%) of CK7+/CK20- metastatic tumors, whereas it represented only 38% of primary tumor in the second group of a known primary site (P=0.006). Given the fact that metastatic tumors to the craniospinal axis of an unknown primary site are frequently CK7+/CK20-, and they have commonly metastasized from the lung, it is doubtful that immunohistochemistry is really helpful. However, CT scan and MRI of the chest still play an important role. Many patients in the present study had to undertake these imaging studies, regardless of the CK7/CK20 result. The immunostains may be useful in cases with other expression profiles, but such examples constituted only a minority in the present study.
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Affiliation(s)
- Mana Taweevisit
- Department of Pathology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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Abstract
Between January 1985 and December 2000, 916 patients with brain metastases were treated with whole brain radiation therapy (WBRT) at the Department of Radiotherapy, University Hospital Freiburg. In 47 patients, a primary tumor could not be identified (cancer of unknown primary (CUP)). Sixteen patients had a solitary brain metastasis, 31 patients presented with multiple brain metastases. Surgical resection was performed in 15 patients, biopsy alone in 12 patients. WBRT was applied with daily fractions of 2 or 3 Gy to a total dose of 50 or 30 Gy, respectively. According to the recursive partitioning analysis (RPA) classes of the Radiation Therapy Oncology Group for patients with brain metastases none of the patients met the criteria for Class I, 23 for Class II, and 24 for Class III. The median overall survival (OS) for all patients with brain metastases (n = 916) was 3.4 and 4.8 months for patients with CUP (p = 0.45). In patients with CUP (n = 47) the median OS for patients with a single brain metastasis was 7.3 versus 3.9 months for patients with multiple brain metastases (p = 0.05). Median OS for patients with a Karnofsky performance status (KPS) > or = 70 was 6.3 months versus 3.2 months for KPS < 70 (p = 0.01). At multivariate analysis performance status and resection status could be identified as independent prognostic factors for the OS.
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Affiliation(s)
- Susanne Bartelt
- Department of Radiation Oncology, University of Freiburg, Freiburg i. Br, Germany.
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Pavlidis N, Briasoulis E, Hainsworth J, Greco FA. Diagnostic and therapeutic management of cancer of an unknown primary. Eur J Cancer 2003; 39:1990-2005. [PMID: 12957453 DOI: 10.1016/s0959-8049(03)00547-1] [Citation(s) in RCA: 370] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Metastatic Cancer of Unknown Primary Site (CUP) accounts for approximately 3% of all malignant neoplasms and is therefore one of the 10 most frequent cancer diagnoses in man. Patients with CUP present with metastatic disease for which the site of origin cannot be identified at the time of diagnosis. It is now accepted that CUP represents a heterogeneous group of malignancies that share a unique clinical behaviour and, presumably, unique biology. The following clinicopathological entities have been recognised: (i) metastatic CUP primarily to the liver or to multiple sites, (ii) metastatic CUP to lymph nodes including the sub-sets involving primarily the mediastinal-retroperitoneal, the axillary, the cervical or the inguinal nodes, (iii) metastatic CUP of peritoneal cavity including the peritoneal papillary serous carcinomatosis in females and the peritoneal non-papillary carcinomatosis in males or females, (iv) metastatic CUP to the lungs with parenchymal metastases or isolated malignant pleural effusion, (v) metastatic CUP to the bones, (vi) metastatic CUP to the brain, (vii) metastatic neuroendocrine carcinomas and (viii) metastatic melanoma of an unknown primary. Extensive work-up with specific pathology investigations (immunohistochemistry, electron microscopy, molecular diagnosis) and modern imaging technology (computed tomography (CT), mammography, Positron Emission Tomography (PET) scan) have resulted in some improvements in diagnosis; however, the primary site remains unknown in most patients, even on autopsy. The most frequently detected primaries are carcinomas hidden in the lung or pancreas. Several favourable sub-sets of CUP have been identified, which are responsive to systemic chemotherapy and/or locoregional treatment. Identification and treatment of these patients is of paramount importance. The considered responsive sub-sets to platinum-based chemotherapy are the poorly differentiated carcinomas involving the mediastinal-retroperitoneal nodes, the peritoneal papillary serous adenocarcinomatosis in females and the poorly differentiated neuroendocrine carcinomas. Other tumours successfully managed by locoregional treatment with surgery and/or irradiation are the metastatic adenocarcinoma of isolated axillary nodes, metastatic squamous cell carcinoma of cervical nodes, or any other single metastatic site. Empirical chemotherapy benefits some of the patients who do not fit into any favourable sub-set, and should be considered in patients with a good performance status.
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Affiliation(s)
- N Pavlidis
- University of Ioannina Hospital, Department of Medical Oncology, 451 10, Ioannina, Greece.
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Tan TC, McL Black P. Image-guided craniotomy for cerebral metastases: techniques and outcomes. Neurosurgery 2003; 53:82-9; discussion 89-90. [PMID: 12823876 DOI: 10.1227/01.neu.0000068729.37362.f9] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2001] [Accepted: 03/03/2003] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The purpose of the present study was to analyze the outcomes after craniotomies for brain metastases in a modern series using image-guided technologies either in the regular operating room or in the intraoperative magnetic resonance imaging unit. METHODS Neurosurgical outcomes were analyzed for 49 patients who underwent 55 image-guided craniotomies for excision of brain metastases during a 5-year period. Tumors were located in critical and noncritical function regions of the brain. A total of 23 craniotomies for tumors in critical brain were performed using intravenous sedation anesthesia; craniotomies for noncritical function brain regions were completed under general anesthesia. The patients were also divided into Radiation Therapy Oncology Group recursive partitioning analysis (RPA) classes on the basis of age, Karnofsky Performance Scale scores, state of primary disease, and presence or absence of extracranial metastases. RESULTS There was no perioperative mortality. Gross total resection, as verified by postoperative contrast-enhanced computed tomography or magnetic resonance imaging, was achieved in 96% of patients. The median anesthesia time was 4.25 hours, and the median length of hospital stay was 3 days. In 51 symptomatic cases, there was complete resolution of symptoms in 70% (n = 36), improvement in 14% (n = 7), and no change in 12% (n = 6) postoperatively. No patient who was neurologically intact preoperatively deteriorated after surgery, and 93% of patients maintained or improved their functional status. Only two patients (3.6%) with significant preoperative deficits had increased long-term deficits postoperatively. The mean follow-up was 1 year, and the local recurrence rate was 16%. The median survival of the entire group was 16.23 months (17.5 mo in RPA Class I, 22.9 mo in RPA Class II, and 9.8 mo in RPA Class III). CONCLUSION Gross total resection of brain metastases, including those involving critical function areas, can be safely achieved with a low morbidity rate using contemporary image-guided systems. RPA Class I and II patients with controlled primary disease benefit from aggressive treatment by surgery and radiation.
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Affiliation(s)
- Tze-Ching Tan
- Department of Neurosurgery, Brigham and Women's Hospital, Department of Surgery, Harvard Medical School, Boston, Massachusetts 02215, USA
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Wang LG, Guo Y, Zhang X, Song SJ, Xia JL, Fan FY, Shi M, Wei LC. Brain metastasis: experience of the Xi-Jing hospital. Stereotact Funct Neurosurg 2003; 78:70-83. [PMID: 12566833 DOI: 10.1159/000068015] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The management of metastatic brain tumors is an important issue in patients with malignant tumors or cancer. The authors summarize the results of patients with brain metastases treated at the Xi-Jing Hospital during a 10-year period, in order to assess the best modality of treatment for patients with brain metastases. METHODS Between 1990 and 2000, 463 patients with brain-metastatic tumors were treated at the Xi-Jing Hospital of the Fourth Military Medical University, Xian, China. In most patients, the pathologic diagnosis of primary cancer was obtained before they were referred for their brain metastasis. There were 34 (8.42%) cases with an unknown primary cancer site at the time of initial presentation. Patients were grouped according to treatment methods, which included neurosurgical craniotomy (NS; 130 patients), whole-brain radiotherapy (WBRT; 120 patients). Linac XKnife radiosurgery (RS; 130 patients) and Linac XKnife radiosurgery plus WBRT (RT; 83 cases). Survival was measured from the time of treatment and was analyzed by the Kaplan-Meier product-limit method and then plotted. Differences between curves were evaluated using the log-rank test. Multivariate factors associated with survival were analyzed using the Cox proportional hazards model. RESULTS The survival time was 68.4 +/- 7.20 weeks after NS, 51.3 +/- 5.04 weeks after WBRT, 67.9 +/- 3.68 weeks after RS and 89.7 +/- 4.50 weeks after RT. The presence of active systemic cancer in a larger number of metastatic tumors was associated with a poor survival (p = 0.0003 and 0.0000). The female patients showed better survival rates over the male ones (p = 0.0000). Patients treated with RT had a better survival than those treated with NS, WBRT and RS (p = 0.0048, 0.0000 and 0.1222, respectively), although the latter did not show statistical significance. CONCLUSIONS RS was an effective modality for patients with brain metastases, and if combined with WBRT, survival was better. Progression of systemic cancer and the number of metastatic tumors were the most significant factors for a poor survival after treatment of the brain metastases.
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Affiliation(s)
- Li Gen Wang
- Department of Neurosurgery, Xi-Jing Hospital, Fourth Military Medical University, Xian, People's Republic of China.
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Abstract
In recent years, a broader base of treatment options has evolved to improve the outcome for patients with brain metastases. The selection of the most appropriate intervention for the individual patient is dependent on a careful evaluation of the extent of intracranial tumour, as well as an understanding of patient and tumour characteristics that are important determinants of prognosis. Recent analyses have confirmed good performance status, control of the primary tumour, absence of extracranial metastases and age less than 65 years to be predictors for longer survival. Medical therapy typically includes the use of corticosteroids, and some advances have been made in optimising the use of these agents. Prophylactic use of antiepileptic drugs in patients with brain metastases is generally discouraged. Chemotherapy was previously not considered to have a role in treating brain metastases, but has increasingly become an accepted treatment option. Recent clinical studies have evaluated the integration of chemotherapy with conventional treatments such as radiotherapy and the addition of biological response modifiers. In the past, radiotherapy has been the mainstay of treatment for brain metastases. A number of randomised controlled trials have explored external beam radiation therapy, radiation sensitisers, postoperative whole brain irradiation and prophylactic cranial irradiation. Significant improvements in survival have been demonstrated as a result of prophylactic cranial irradiation in patients with small-cell lung cancer, and improved local control of brain metastases has been achieved with postoperative whole brain irradiation. A number of studies have helped define a more efficient use of external beam irradiation. Radiosurgery in particular has been identified as an important advance in radiation treatment delivery and may provide an acceptable alternative to surgical resection in many patients. Conventional surgery has long had a role to play in establishing the diagnosis, guiding the choice of subsequent therapies and reversing life-threatening complications from brain metastases. The risks of surgery have been reduced with recent improvements in anaesthesia and intraoperative tumour localisation. Recent clinical studies have addressed the role of surgical resection in the management of patients with a single brain metastasis. Survival benefits have been demonstrated in patients undergoing surgical resection in addition to external beam radiation therapy. Despite the improvements achieved in the treatment of patients with brain metastases at first diagnosis, the question of retreatment may arise in due course. The therapeutic options available in this situation include re-operation, radiosurgery and brachytherapy.
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Affiliation(s)
- Phillip Davey
- Division of Radiation Oncology, The Toronto-Sunnybrook Regional Cancer Centre, Ontario, Canada
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Raff JP, Anderson P, Sands C, Makower D. Fallopian tube carcinoma presenting with a brain metastasis. Gynecol Oncol 2002; 85:372-5. [PMID: 11972403 DOI: 10.1006/gyno.2002.6595] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Fallopian tube carcinoma is a rare gynecologic cancer. An extensive literature search reveals no previous case report of fallopian tube carcinoma presenting with a brain metastasis. CASE A 63-year-old woman presented with 3 weeks of progressive left-sided weakness. CT scan of the brain revealed a solitary lesion in the right parietal lobe. The patient underwent a complete resection, followed by whole-brain radiation therapy. Pathologic review demonstrated adenocarcinoma with follicular structures. A directed workup revealed a large right adnexal mass. She underwent resection of a large fallopian tube carcinoma with normal ovaries. She recovered from surgery and is receiving combination chemotherapy. CONCLUSION This is the first case report of a fallopian tube carcinoma presenting as a brain metastasis.
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Affiliation(s)
- Joshua P Raff
- Department of Medical Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA
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39
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Abstract
Metastatic tumors to the brain are an increasing cause of morbidity and mortality in patients with systemic cancers. Many new therapies used to treat systemic cancers do not penetrate the central nervous system (CNS) and do not protect patients from the development of brain metastases. Surgery, radiosurgery, and radiation therapy are all used to treat brain metastases. It is in our opinion a mistake to use only one or two of these modalities to the exclusion of other(s). The role of systemic chemotherapy is still limited, due to both the issues of drug delivery caused by the blood brain barrier and to the relative resistance of many of these tumors to chemotherapy. Traditionally, brain metastases have been grouped together regardless of the origin of the tumor and have been treated with a single algorithm. As we encounter more patients for whom treatment of the brain metastases is an important determinant of survival, we must tailor our treatment strategies to individual tumor types. Also, we must recognize differences in each tumor's sensitivity to chemotherapy and radiotherapy and differences in their biology.
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Affiliation(s)
- M G Ewend
- Division of Neurosurgery, University of North Carolina at Chapel Hill, 148 Burnett-Womack Building, Campus Box 7060, Chapel Hill, NC 27599-7060, USA.
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40
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Jacot W, Quantin X, Boher JM, Andre F, Moreau L, Gainet M, Depierre A, Quoix E, Chevalier TL, Pujol JL. Brain metastases at the time of presentation of non-small cell lung cancer: a multi-centric AERIO analysis of prognostic factors. Br J Cancer 2001; 84:903-9. [PMID: 11286469 PMCID: PMC2363840 DOI: 10.1054/bjoc.2000.1706] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
A multi-centre retrospective study involving 4 French university institutions has been conducted in order to identify routine pre-therapeutic prognostic factors of survival in patients with previously untreated non-small cell lung cancer and brain metastases at the time of presentation. A total of 231 patients were recorded regarding their clinical, radiological and biological characteristics at presentation. The accrual period was January 1991 to December 1998. Prognosis was analysed using both univariate and multivariate (Cox model) statistics. The median survival of the whole population was 28 weeks. Univariate analysis (log-rank), showed that patients affected by one of the following characteristics proved to have a shorter survival in comparison with the opposite status of each variable: male gender, age over 63 years, poor performance status, neurological symptoms, serum neuron-specific enolase (NSE) level higher than 12.5 ng ml(-1), high serum alkaline phosphatase level, high serum LDH level and serum sodium level below 132 mmol l(-1). In the Cox's model, the following variables were independent determinants of a poor outcome: male gender: hazard ratio (95% confidence interval): 2.29 (1.26-4.16), poor performance status: 1.73 (1.15-2.62), age: 1.02 (1.003-1.043), a high serum NSE level: 1.72 (1.11-2.68), neurological symptoms: 1.63 (1.05-2.54), and a low serum sodium level: 2.99 (1.17-7.62). Apart from 4 prognostic factors shared in common with other stage IV NSCLC patients, whatever the metastatic site (namely sex, age, gender, performance status and serum sodium level) this study discloses 2 determinants specifically resulting from brain metastasis: i.e. the presence of neurological symptoms and a high serum NSE level. The latter factor could be in relationship with the extent of normal brain tissue damage caused by the tumour as has been demonstrated after strokes. Additionally, the observation of a high NSE level as a prognostic determinant in NSCLC might reflect tumour heterogeneity and understimated neuroendocrine differentiation.
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Affiliation(s)
- W Jacot
- Department of Chest Diseases, Hôpital Universitaire Arnaud de Villeneuve, 34295 Montpellier Cedex 5, France
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Giordana MT, Cordera S, Boghi A. Cerebral metastases as first symptom of cancer: a clinico-pathologic study. J Neurooncol 2000; 50:265-73. [PMID: 11263507 DOI: 10.1023/a:1006413001375] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Symptomatic brain metastases of carcinomas in patients without a previously diagnosed malignancy are frequent in neurosurgical series. Such tumors often lack distinctive morphological characteristics so that the routine histological examination can be unsuccessful in identifying the site of origin. Objectives of the present study were to evaluate the frequency of brain metastases as the only manifestation of an unknown primary cancer by the retrospective analysis of a series of consecutively operated single cerebral metastases; to verify the efficacy of clinical investigations in detecting the site of origin; to investigate whether the primary site can be identified by the immunohistochemical study of the neurosurgical specimens. Antibodies to the following antigens were used: carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 19.9, CA 125, BCA-225, cytokeratin 20, PSA, HMB-45. Out of 181 patients operated for single cerebral metastasis of carcinoma, 99 (54.7%) were in patients without any previously diagnosed systemic neoplasm. In 26.7% the primary remained undiagnosed after clinical investigations, in 9 cases even at autopsy. PSA and HMB45 antibodies specifically identified metastases from prostate carcinomas and skin melanomas, respectively. No other specific immunophenotype was identified; the immunoreactivity of the single cases was more or less suggestive for a primary site. Precocious metastases of lung carcinomas expressed CEA more frequently than late metastases. It has been hypothesized that CEA plays some role as a contact mediating device. CEA expression can have some link with the tendency to metastasize precociously to the brain. No major difference of p53 and k-ras expression has been found in precocious versus late brain metastases.
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Affiliation(s)
- M T Giordana
- Department of Neuroscience, University of Turin, Italy.
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Rhodes RH, Wightman HR. Nucleus of the tractus solitarius metastasis: relationship to respiratory arrest? Can J Neurol Sci 2000; 27:328-32. [PMID: 11097526 DOI: 10.1017/s0317167100001104] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND A 52-year-old woman with metastases in brain and bone had clinical and radiological response to therapy but died about 10 weeks after diagnosis. General autopsy failed to identify a primary neoplasm or an anatomic cause of death. Investigation of sudden respiratory cessation was a consideration when undertaking an anatomic study of the brain. METHODS Review of patient records and careful examination of the brain following autopsy were carried out. RESULTS The patient had terminal episodes of hypersomnia but episodes of sleep apnea were not observed. She received no respiratory support and no respiratory difficulties were recorded until she was pronounced dead at 7 a.m. Autopsy revealed metastatic adenocarcinoma in a pattern suggestive of a primary pulmonary neoplasm, including multiple cerebral metastases, although no significant pulmonary lesions of any type were found. A 0.2 cm metastatic adenocarcinoma was found in the nucleus of the tractus solitarius (NTS). No other tumor was present in the brain stem. CONCLUSIONS Unilateral destruction of the NTS in the medulla would have severely disturbed the most critical point of convergence of autonomic and voluntary respiratory control and of cardiocirculatory reflexes in the central autonomic network. It is postulated that this caused respiratory arrest during a state transition from sleeping to waking. Few metastases to the medulla are reported, most are relatively large, and several have caused respiratory symptoms before death. The very small metastasis in our patient could be the direct anatomic cause of death, and as such it is an unusual complication of metastatic disease of which clinicians should be aware. It is speculated that dysfunction of direct NTS connections to the pons or of connections passing close to the metastatic deposit resulted in terminal hypersomnia.
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Affiliation(s)
- R H Rhodes
- Department of Pathology, University of Manitoba, Winnipeg, Canada
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Abstract
BACKGROUND The care of patients with a brain metastasis from unknown primary site is controversial. The authors reviewed the results of stereotactic radiosurgery in this group of patients to better define clinical expectations. METHODS During an 11-year interval, radiosurgery was performed in 421 patients with brain metastases at the University of Pittsburgh. Fifteen patients had solitary or multiple (< or = 5) brain metastases without a detectable primary site at the time of initial presentation. In five patients, a histologic diagnosis of cancer was obtained from extracranial metastatic sites. In 10 patients, a diagnosis was obtained from the brain. A total of 31 tumors with a mean volume of 4.3 mL (range, 0. 05-18.6 mL) underwent radiosurgery with a mean marginal dose of 16.2 Gray (Gy) (range, 12-20 Gy). Fourteen patients (93.3%) also received whole brain fractionated radiation therapy. RESULTS The median survival was 15 months after radiosurgery (range, 1-48 months) and 27 months after their initial diagnosis of cancer. In 4 patients (26. 7%), the primary tumor was discovered later (lung in 3 patients and liver in 1). Three of these four patients died due to progression of their primary tumor. Of the remaining 11 patients, 4 died of progression of extracranial metastases, 2 died of other systemic diseases, and 3 patients died because of progression of brain metastasis. Three patients (20%) were still living between 21-48 months after radiosurgery. The presence of active systemic disease and brain stem location both were associated with a poor outcome (P = 0.004 and 0.04). The actuarial imaging-defined local tumor control rate was 91.3 +/- 5.9% at 4 years. CONCLUSIONS Radiosurgery was an effective strategy for patients with brain metastases from an unknown primary site. Disease progression outside of the brain was the usual cause for patient death.
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Affiliation(s)
- S Maesawa
- Department of Neurological Surgery, Center for Image-Guided Neurological Surgery, University of Pittsburgh, PA 15213, USA
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Maguire D, O'Sullivan GC, McNamara B, Collins JK, Shanahan F. Bone-marrow micrometastases in patients with brain metastases from epithelial cell tumours. QJM 2000; 93:611-5. [PMID: 10984556 DOI: 10.1093/qjmed/93.9.611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Carcinoma that has metastasized to the central nervous system (CNS) poses a particular clinical problem regarding confirmation of the diagnosis and subsequent management. Prior to excision, thorough evaluation for coexisting systemic disease is essential, but current imaging techniques are limited by their spatial resolution and under-stage many patients. We evaluated the potential utility of bone-marrow evaluation for micrometastatic cells in patients with CNS metastasis. Bone-marrow aspirates were examined for cytokeratin-positive cells in 12 consecutive patients who presented with symptomatic space-occupying lesions of the CNS. These patients had previously undergone surgical excision of either gastrointestinal or breast cancers. All twelve had micrometastases in their bone marrow at the time of presentation with the CNS disease and all had a fatal outcome within 13 months. In nine of the 12 patients, bone-marrow micrometastases were the only evidence for systemic spread. Three patients had elevated serum tumour markers and two of these had radiologically detectable recurrence elsewhere. Bone-marrow micrometastases indicate concurrent systemic involvement and a poor prognosis. The results suggest that bone-marrow evaluation for systemic spread is a useful diagnostic adjunct and should be performed before considering diagnostic biopsy or excision.
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Affiliation(s)
- D Maguire
- Cork Cancer Research Centre, Department of Surgery, Mercy Hospital and. the Departments of Medicine and Surgery, University College Cork, National University of Ireland, Cork
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