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

The safety and efficacy of stereotactic radiosurgery in patients with gastrointestinal cancer brain metastasis: a systematic review and meta-analysis

Central nervous system Tumors, including metastasis, are a considerable source of morbidity and mortality. Currently, treatment options such as surgery, radiotherapy, and chemotherapy have been introduced to prevent the progression of the disease, but still, these patients do not have a good prognosis. Stereotactic radiosurgery (SRS) reduces the damage to the surroundings by focusing the radiation on the tumor tissue. In this paper, we aim to investigate the outcomes of SRS on patients with gastrointestinal-originated brain metastases. A systematic review and meta-analysis used the PRISMA guideline from inception until 27th March 2024, utilizing the relevant key terms. Records were screened and included based on pre-defined inclusion and exclusion criteria. Demanding data was extracted and analyzed using STATA v. 17. This meta-analysis of 29 studies examining SRS for brain metastases from gastrointestinal cancers revealed several significant findings. The pooled distant intracranial disease rate was 33% (95% CI: 0.21-0.45). Local tumor control rates were high, with an overall pooled rate of 88% (95% CI: 0.83-0.92). Survival outcomes showed a 6-month overall survival (OS) rate of 47% (95% CI: 0.42-0.52), decreasing to 32% at one year and 11% at two years. The 5-year OS rate was 2% (95% CI: 0.01-0.03). Subgroup analyses revealed variations in outcomes based on primary tumor site, with gastric cancer patients showing better short-term survival (73% at six months) compared to hepatic primaries (31% at six months). The 6-month progression-free survival (PFS) rate was 67% (95% CI: 0.12-1.22). Tumor control outcomes showed complete regression in 11% of cases, partial regression in 44%, stable disease in 30%, and progression in 20%. The overall mortality rate was 84% (95% CI: 0.75-0.93). This meta-analysis supports the efficacy of SRS in managing brain metastases from gastrointestinal cancers. SRS offers effective local control and may improve quality of life despite poor long-term outcomes. The high rates of distant intracranial progression underscore the need for comprehensive management strategies addressing both local and systemic disease. Future research should optimize patient selection, combine SRS with novel systemic therapies, and identify predictive biomarkers to improve outcomes in this challenging patient population.

Stereotactic Radiosurgery for Patients with Brain Metastases from Hepatopancreaticobiliary Cancers

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Risk Factors for Brain Metastasis of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a common malignancy with high mortality, especially in HCC patients with brain metastases (BMS). However, few studies have investigated the risk factors for BMS among HCC patients based on large-scale population. The study involved clinical data of 36,091 patients who met the inclusion criteria from the SEER database, from 2004 to 2016. Univariate analysis and multifactor logistics regression analysis was used to analyze risk factors affecting BMS among HCC patients. This study revealed that BMS occurred in 108 of 36,091 patients, with an incidence of 0.33%. Median survival was 7 months for patients with BMS, but 12 months for patients without BMS. Univariate analysis showed that pathological low differentiation and undifferentiation, lymph node metastasis, no surgical treatment, and no chemotherapy and radiotherapy increased risk of BMS (P < 0.05). Multivariate analysis suggested that no surgical treatment and no chemotherapy or radiotherapy were independent risk factors for BMS (P < 0.001). Our findings highlighted that the independent risk factors for BMS were no surgical treatment, no chemotherapy, and no radiotherapy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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