Brain metastases of epithelial ovarian carcinoma responding to cisplatin and gemcitabine combination chemotherapy: a case report and review of the literature

Therapeutic Options for Brain Metastases in Gynecologic Cancers

OPINION STATEMENT

Brain metastases (BM) are rare in gynecologic cancers. Overall BM confers a poor prognosis but other factors such as number of brain lesions, patient age, the presence of extracranial metastasis, the Karnofsky Performance Status (KPS) score, and the type of primary cancer also impact prognosis. Taking a patient's whole picture into perspective is crucial in deciding the appropriate management strategy. The management of BM requires an interdisciplinary approach that frequently includes oncology, neurosurgery, radiation oncology and palliative care. Treatment includes both direct targeted therapies to the lesion(s) as well as management of the neurologic side effects caused by mass effect. There is limited evidence of when screening for BM in the gynecology oncology patient is warranted but it is recommended that any cancer patient with new focal neurologic deficit or increasing headaches should be evaluated. The primary imaging modality for detection of BM is MRI, but other imaging modalities such as CT and PET scan can be used for certain scenarios. New advances in radiation techniques, improved imaging modalities, and systemic therapies are helping to discover BM earlier and provide treatments with less detrimental side effects.

Cauda equina syndrome secondary to leptomeningeal metastases from recurrent primary peritoneal carcinoma

The patient is a 42-year-old woman with metastatic primary peritoneal carcinoma and known brain metastases, who subsequently developed cauda equina syndrome after presenting with ataxia, lower extremity weakness, and bowel and bladder incontinence secondary to leptomeningeal metastasis after treatment with neoadjuvant chemotherapy, surgical debulking, and adjuvant chemotherapy. Metastases to the central nervous system (CNS) and leptomeninges are rare events in epithelial ovarian and primary peritoneal carcinomas as these tumours do not have a predilection for the CNS. Cauda equina syndrome is often characterised by gait disturbances, bowel and bladder dysfunction, saddle anaesthesia, and lower extremity muscle weakness. In patients with known metastatic gynaecologic carcinomas presenting with nonspecific neurologic symptoms, cauda equina syndrome should remain high in the differential diagnosis.

Treatment of brain metastases

BACKGROUND

Brain metastases are a very common neurological sequela in cancer patients. The ability of current anti-cancer therapies to prolong overall survival is beleaguered by this development in the case of a number of different cancers. This review provides a general overview of relevant treatment modalities, highlights major decision strategies used in selecting the optimal treatment algorithm and summarizes important steps necessary before initiating therapy.

METHODS

A PubMed database search was done to identify publications describing the treatment of brain metastases including surgery, radiotherapy and symptomatic care.

RESULTS AND CONCLUSION

Patient performance status and extent of disease play the most important roles in selecting between an aggressive or more conservative approach. As several other options are available, treatment decisions should be made in cooperation with multiple medical specialties and the involvement of multidisciplinary teams. In the future, brain metastases could become less of a treatment obstacle than they are today.

Clinicopathologic characteristics and survival of patients with gynecologic malignancies metastatic to the brain

OBJECTIVE

No standardized treatment strategies exist for patients with gynecologic malignancies complicated by brain metastases. Identification of poor outcome characteristics, long-term survival indicators, and molecular markers could help individualize and optimize treatment.

METHODS

This retrospective cohort study included 100 gynecologic cancer patients with brain metastases treated at our institution between January 1990 and June 2009. Primary outcome was overall survival (OS) from time of diagnosis of brain metastases. We used univariate and multivariate analyses to evaluate associations between OS and clinical factors. We used immunohistochemistry to examine expression of five molecular markers in primary tumors and brain metastases in a subset of patients and matched controls. Statistical tests included the Student's paired t-test (for marker expression) and Kaplan-Meier test (for correlations).

RESULTS

On univariate analysis, primary ovarian disease, CA-125<81units/mL at brain metastases diagnosis, and isolated versus multi-focal metastases were all associated with longer survival. Isolated brain metastasis remained the only significant predictor on multivariate analysis (HR 2.66; CI 1.19-5.93; p=0.017). Expression of vascular endothelial growth factor A (VEGF-A) was higher in metastatic brain samples than in primary tumors of controls (p<0.0001). None of the molecular markers were significantly associated with survival.

CONCLUSIONS

Multi-modality therapy may lead to improved clinical outcomes, and VEGF therapy should be investigated in treatment of brain metastases.

Pharmacokinetic Properties of Anticancer Agents for the Treatment of Central Nervous System Tumors: Update of the Literature

Despite significant improvement in outcomes for patients with hematologic malignancies and solid tumors over the past 10 years, patients with primary or metastatic brain tumors continue to have a poor prognosis. A primary reason for this is the inability of many chemotherapeutic drugs to penetrate into the brain and brain tumors at concentrations high enough to exert an antitumor effect because of unique barriers and efflux transporters. Several studies have been published recently examining the central nervous system pharmacokinetics of various anticancer drugs in patients with primary and metastatic brain tumors. To summarize recent advances in the field, this review critically presents studies published within the last 9 years examining brain and cerebrospinal fluid penetration of clinically available anticancer agents for patients with central nervous system tumors.

Platinum sensitivity and CD133 expression as risk and prognostic predictors of central nervous system metastases in patients with epithelial ovarian cancer

Background

To characterize prognostic and risk factors of central nervous system (CNS) metastases in patients with epithelial ovarian cancer (EOC).

Methods

A retrospective analysis of Xijing Hospital electronic medical records was conducted to identify patients with pathologically confirmed EOC and CNS metastases. In addition to patient demographics, tumor pathology, treatment regimens, and clinical outcomes, we compared putative cancer stem cell marker CD133 expression patterns in primary and metastatic lesions as well as in recurrent EOC with and without CNS metastases.

Results

Among 1366 patients with EOC, metastatic CNS lesions were present in 29 (2.1%) cases. CD133 expression in primary tumor was the only independent risk factor for CNS metastases; whilst the extent of surgical resection of primary EOC and platinum resistance were two independent factors significantly associated with time to CNS metastases. Absence of CD133 expression in primary tumors was significantly associated with high platinum sensitivity in both patient groups with and without CNS metastases. Platinum resistance and CD133 cluster formation in CNS metastases were associated with decreased survival, while multimodal therapy including stereotactic radiosurgery (SRS) for CNS metastases was associated with increased survival following the diagnosis of CNS metastases.

Conclusions

These data suggest that there exist a positive association between CD133 expression in primary EOC, platinum resistance and the increased risk of CNS metastases, as well as a less favorable prognosis of EOC. The absence of CD133 clusters and use of multimodal therapy including SRS could improve the outcome of metastatic lesions. Further investigation is warranted to elucidate the true nature of the association between platinum sensitivity, CD133 expression, and the risk and prognosis of CNS metastases from EOC.

A late, solitary brain metastasis of epithelial ovarian carcinoma

Background

Brain metastasis from epithelial ovarian cancer (EOC) is very rare with a reported incidence of less than 2%. It is usually associated with a poor prognosis that is related to several factors, the most important including: single vs multiple lesions, performance status, platinum-sensitive disease, tumor grade, extracranial disease, and multimodal approach treatment. At the time of diagnosis, an extracranial disease is found in over half of patients. The most common histology is the serous type. The median time from primary diagnosis to development of cerebral lesions is directly correlated to initial tumor grade and stage. Several therapeutic approaches can be proposed, including best supportive care +/- corticosteroids, surgery, radiotherapy and chemotherapy. A multimodal therapy approach may achieve an improved outcome and should therefore be utilized whenever applicable.

Case presentation

We present the case of a patient with a solitary brain metastasis which appeared 11 years after a locally advanced and aggressive EOC (FIGO stage III C) and which totally regressed after surgery and adjuvant chemotherapy. Clinically, she showed progressive headaches, decreased visual acuity, balance and memory disorders associated with a confusional state. Brain CT scan and MRI documented a solitary, necrotic lesion in the left central parietal region with an important cerebral surrounding edema and initial cranial herniation. No other extracranial metastases were observed at the PET scan. Laboratory tests were in the normal range and CA 125 was moderatly increased at 81 UI/ml. The patient underwent surgical removal of tumor lesion, post-surgical whole-brain radiotherapy (WBRT) and systemic chemotherapy with carboplatin alone for six cycles. At a follow-up of 13 months, she is alive, in good clinical condition and tumor progression free.

Conclusion

The peculiarity of this case relies on the isolated brain relapse of a BRCA-1/BRCA-2 non-mutated EOC, which is uncommon and rare, and to the very long time, of 11 years, from diagnosis of primary cancer and development of brain metastasis. A multimodal, aggressive approach of this isolated brain metastasis led to a complete and prolonged tumor control.

Brain metastasis from ovarian cancer: a systematic review

To review the existing literature on brain metastasis (BM) from ovarian cancer and to assess the frequency, anatomical, clinical and paraclinical information and factors associated with prognosis. Ovarian cancer is a rare cause of brain metastasis with a recently reported increasing prevalence. Progressive neurologic disability and poor prognosis is common. A comprehensive review on this subject has not been published previously. This systematic literature search used the Pubmed and Yale library. A total of 66 publications were found, 57 of which were used representing 591 patients with BM from ovarian cancer. The median age of the patients was 54.3 years (range 20-81). A majority of patients (57.3 %) had multiple brain lesions. The location of the lesion was cerebellar (30 %), frontal (20 %), parietal (18 %) and occipital (11 %). Extracranial metastasis was present in 49.8 % of cases involving liver (20.7 %), lung (20.4 %), lymph nodes (12.6 %), bones (6.6 %) and pelvic organs (4.3 %). The most common symptoms were weakness (16 %), seizures (11 %), altered mentality (11 %) visual disturbances (9 %) and dizziness (8 %). The interval from diagnosis of breast cancer to BM ranged from 0 to 133 months (median 24 months) and median survival was 8.2 months. Local radiation, surgical resection, stereotactic radiosurgery and medical therapy were used. Factors that significantly increased the survival were younger age at the time of ovarian cancer diagnosis and brain metastasis diagnosis, lower grade of the primary tumor, higher KPS score and multimodality treatment for the brain metastases. Ovarian cancer is a rare cause of brain metastasis. Development of brain metastasis among older patients and lower KPS score correlate with less favorable prognosis. The more prolonged survival after using multimodality treatment for brain metastasis is important due to potential impact on management of brain metastasis in future.

Brain metastases in women with epithelial ovarian cancer: multimodal treatment including surgery or gamma-knife radiation is associated with prolonged survival

OBJECTIVE

To explore the impact of treatment modality on survival in patients with brain metastases from epithelial ovarian cancer.

METHODS

We conducted a retrospective review of cases of ovarian cancer with brain metastases treated at institutions in three countries (Canada, China, and India) and conducted a search for studies regarding brain metastases in ovarian cancer reporting survival related to treatment modality. Survival was analyzed according to treatment regimens involving (1) some form of surgical excision or gamma-knife radiation with or without other modalities, (2) other modalities without surgery or gamma-knife radiation, or (3) palliation only.

RESULTS

Twelve patients (mean age 56 years) with detailed treatment/outcome data were included; five were from China, four from Canada, and three from India. Median time from diagnosis of ovarian cancer to brain metastasis was 19 months (range 10 to 37 months), and overall median survival time from diagnosis of ovarian cancer was 38 months (13 to 82 months). Median survival time from diagnosis of brain metastasis was 17 months (1 to 45 months). Among patients who had multimodal treatment including gamma-knife radiotherapy or surgical excision, the median survival time after the identification of brain metastasis was 25.6 months, compared with 6.0 months in patients whose treatment did not include this type of focused localized modality (P = 0.006). Analysis of 20 studies also indicated that use of gamma-knife radiotherapy and excisional surgery in multi-modal treatment resulted in improved median survival interval (25 months vs. 6.0 months, P < 0.001).

CONCLUSION

In the subset of patients with brain metastases from ovarian cancer, prolonged survival may result from use of multidisciplinary therapy, particularly if metastases are amenable to localized treatments such as gamma-knife radiotherapy and surgical excision.

Long-term disease-free survival in a patient with cerebral recurrence from adenocarcinoma of the fallopian tube

Cerebral recurrence from Müllerian cancer is a rare event and prognosis of patients with such a condition is poor. We report a case of cerebral recurrence from International Federation of Gynecology and Obstetrics classification stage IV tubal cancer presenting with inguinal lymphadenopathy. The patient achieved more than 7 years' disease-free survival after irradiation to the brain despite the inauspicious event. The present case had a rare clinical course in terms of primary site, primary symptom, failure site, and clinical outcome. Patients with brain metastasis from Müllerian cancer have a chance for long-term survival under specified circumstances, such as solitary metastasis, no extracranial metastasis, no recurrence preceding brain metastasis and small tumor size.

Gamma knife surgery for brain metastases from ovarian cancer

Background

Brain metastases from ovarian cancer are rare, but their incidence is increasing. The purpose of this study was to investigate the characteristics of brain metastases from ovarian cancer, and to assess the efficacy of treatment with gamma knife surgery (GKS).

Methods

A retrospective review was performed of patients with brain metastases from ovarian cancer who were treated at the Tokyo Gamma Unit Center from 2006 to 2010.

Results

Sixteen patients were identified. Their median age at diagnosis of brain metastases was 56.5 years, the median interval from diagnosis of ovarian cancer to brain metastases was 27.5 months, and the median number of brain metastases was 2. The median Karnofsky Performance Score (KPS) at the first GKS was 80. The median survival following diagnosis of brain metastases was 12.5 months, and 6-month and 1-year survival rates were 75 % and 50 %, respectively. The tumor control rate was 86.4 %. The KPS (<80 vs ≥80) and total volume of brain metastases (<10 cm³ vs ≥10 cm³) were significantly associated with survival according to a univariate analysis (p = 0.004 and p = 0.02, respectively).

Conclusions

The results of this study suggest that GKS is an effective remedy and acceptable choice for the control of brain metastases from ovarian cancer.

Increased incidence of brain metastases in BRCA1-related ovarian cancers

AIM

Brain metastasis from ovarian cancer is a very rare phenomenon. BRCA1-related ovarian cancers show specific pathobiological profiles, advanced stage, and sensitivity to chemotherapeutic agents. However, no clear relationship to any known metastatic behavior has yet been found, so we examined the BRCA1 mutation and expression profiles in ovarian cancer cases with brain metastases.

MATERIAL AND METHODS

We examined our clinical records of 340 ovarian cancer cases from 1983 to 2007 to ascertain cases with brain metastases. In the molecular genetic analyses, we performed loss of heterozygosity (LOH), direct sequence and immunohistochemical staining analysis of BRCA1.

RESULTS

We ascertained seven cases with brain metastases in 340 ovarian cancer cases (7/340=2.1%). Among the seven cases, three cases had ovarian and/or breast cancer patients in third-degree relatives. We detected four LOH-positive cases and a germline mutation of BRCA1 in two of the four cases. Furthermore, the remaining two cases showed absent staining of the BRCA1 protein. Therefore, four of seven cases with brain metastases were considered BRCA1-related ovarian cancers (4/7=57.1%). All four of the cases were serous adenocarcinoma.

CONCLUSION

Our results suggest that the loss of BRCA1 function may be involved in the phenomenon of brain metastasis from ovarian cancer. Further molecular biologic analyses will be required for a better understanding of this rare phenomenon.

Central nervous system metastases from epithelial ovarian cancer: prognostic factors and outcomes

OBJECTIVES

To analyze the clinicopathological characteristics and prognostic factors associated with survival in patients with central nervous system (CNS) metastases from epithelial ovarian cancer.

METHODS

Twenty patients with CNS involvement from ovarian carcinoma were evaluated in this retrospective study; their features and survivals were analyzed using Kaplan-Meier and log-rank test methods.

RESULTS

The incidence of CNS metastases was 5%, among 400 patients with ovarian cancer treated in our single institution. The median age at diagnosis of the ovarian cancer was 55 years. The median interval to the brain involvement and the median survival were 33 and 18 months, respectively. Prognostic factors associated with survival were the International Federation of Gynecology and Obstetrics stage, the surgical resection, the multimodal treatment, and the response after the therapy of the brain metastases.

CONCLUSIONS

Brain involvement from ovarian cancer is uncommon but is increasing in incidence. Although the prognosis is usually poor, a multimodal approach can result in a long-term remission of the metastases and in an improvement of the overall survival.

Brain metastases from ovarian carcinoma

This paper will focus on knowledge related to brain metastases from ovarian carcinoma. So far, less than 600 cases were documented in the literature with an incidence among ovarian carcinoma patients ranging from 0.29% to 11.6%. The ovarian carcinoma was usually an advanced-stage epithelial serous carcinoma, and the median interval between diagnosis of ovarian carcinoma and brain metastases was 2 years. Most often, brain metastases, affected the cerebrum, were multiple and part of a disseminated disease. Treatment of brain metastasis has evolved over the years from whole brain radiotherapy (WBRT) only to multimodal therapy including surgical resection or stereotactic radiosurgery followed by WBRT and/or chemotherapy. The median survival after diagnosis of brain metastases was 6 months; nevertheless, a significantly better survival was achieved with multimodal therapy compared to WBRT only. It is suggested that brain imaging studies should be included in the followup of patients after treatment for ovarian carcinoma.

Prognostic role of platinum sensitivity in patients with brain metastases from ovarian cancer: results of a German multicenter study

BACKGROUND

Ovarian cancer is the leading cause of death in women with gynecological malignancies. Brain metastases are considered an uncommon metastatic site. Only few data exist on prognostic factors for this patient collective.

PATIENTS AND METHODS

A multicenter retrospective chart review was carried out including all patients with histologically confirmed ovarian cancer from six different German hospitals from 1981 to 2008. Overall, 4277 cases of patients with ovarian cancer were screened and patients with brain metastasis were identified and analyzed regarding various clinical variables and survival.

RESULTS

A total of 74 women with brain metastases were identified, resulting in an incidence of 1.73%. In multivariate analysis, the following clinical parameters had a significant impact on overall survival: multiple lesions [hazard ratio (HR) 4.4, 95% confidence interval (CI) 2.0-9.7] and low grading (HR 3.1, 95% CI 1.7-5.8) were associated with a negative impact. Platinum sensitivity (HR 0.23, 95% CI 0.12-0.48) was significantly associated with a favorable outcome. Good performance status (60%-80% HR 0.48, 95% CI 0.23-0.99 and 90%-100% HR 0.21, 95% CI 0.08-0.53) also had a positive impact on overall survival.

CONCLUSIONS

Platinum sensitivity is the most important prognostic factor in patients with ovarian cancer metastatic to the brain. This novel finding should be considered in the strategy of multimodal therapy for brain metastases in ovarian cancer.

Extent of extracranial disease is a powerful predictor of survival in patients with brain metastases from gynecological cancer

Central nervous system metastasis from gynecological malignancy is a rare phenomenon that has been described in the past 30 years. The objective of this study is to analyze the treatment modalities and prognostic factors for brain metastases from gynecological tumors that predict prolonged survival. A retrospective chart and pathology review of 47 patients diagnosed with a gynecological tumor with brain metastasis in 1994-2004 was performed. Thirty patients had undergone initial diagnosis and treatment at our institution, and 17 patients were referred following primary treatment at an outside institution. Adjusted Chi-square, Kaplan-Meier survival estimates, log-rank tests, and Cox regression analysis were utilized for statistical analysis of the total cohort. Of the 3146 patients with newly diagnosed gynecological cancer in this 10-year period, 30 developed brain metastasis demonstrating an incidence of 0.95%. Overall median survival from the time of diagnosis of brain metastasis was 7.5 months (95% CI 4-15, range 9 days-64 months) and 40% survival at 1 year. Multivariate analysis revealed evidence of extracranial disease at time of metastasis diagnosis predicted decreased survival (hazard ratio 6.207), while papillary serous histology (hazard ratio 0.42), and use of any chemotherapy (hazard ratio 0.24) predicted longer survival. No other patient or tumor characteristics were found to be independent prognostic indicators affecting survival. Despite the ominous prognosis associated with the development of brain metastasis, these retrospective data suggest that multimodal therapy with whole brain radiation therapy, chemotherapy, and surgical resection of metastases in selected patients without evidence of extracranial and with solitary or multiple lesions can prolong survival.

Enhanced chemotherapy delivery by intraarterial infusion and blood-brain barrier disruption in the treatment of cerebral metastasis

BACKGROUND

Cerebral metastases are clinically significant in 10% to 30% of patients with neoplasia. Multiple cerebral metastases are typically treated with palliative radiotherapy. There is no consensus on the role of enhanced chemotherapy delivery as an adjuvant treatment modality in this disease. In this report, the authors detailed their experience with intraarterial (IA) chemotherapy infusion with and without blood-brain barrier disruption (BBBD) in patients with multiple cerebral metastases.

METHODS

From November 1999 to May 2005, 38 patients with multiple cerebral metastases were enrolled in a prospective study. Patients were treated with IA carboplatin, except for those with cerebral metastases of systemic lymphoma, who were administered IA methotrexate. Osmotic BBBD was offered to patients without the presence of a significant mass effect. These regimens were coupled with intravenous etoposide and cyclophosphamide. Cycles were repeated every 4 weeks.

RESULTS

Survival was calculated from study entry and radiologic response was based on MacDonald criteria. Kaplan-Meier estimates were generated for all subgroups. Mean and median survival obtained was as follows: 34 and 29.6 months for the whole group; 33.6 and 42.3 months for ovarian carcinoma; 15.3 and 13.5 months for lung adenocarcinomas; 8.3 and 8.8 months for small cell lung carcinoma; 8.9 and 8.1 months for breast carcinoma; and 24.8 and 16.3 months, respectively, for cerebral metastasis from systemic lymphoma.

CONCLUSIONS

Even with a small number of patients in each subgroup, the results obtained seem promising for multiple brain metastasis of ovarian carcinoma, adenocarcinoma of lung, small cell lung carcinoma, and systemic lymphoma.

Brain metastases as isolated site of relapse in patients with epithelial ovarian cancer previously treated with platinum and paclitaxel-based chemotherapy

Brain metastases in patients with epithelial ovarian cancer (EOC) have an estimated incidence of 0.3-1.9% and are isolated in up to 50% of these patients. The risk factors and the prognostic significance of isolated central nervous system (CNS) relapse in patients with EOC who received primary treatment with platinum and paclitaxel have not been identified. We conducted a retrospective study in patients with EOC who relapsed with isolated brain metastases and report our experience. Two hundred sixty-seven patients with stages III and IV EOC, in clinical complete remission after first-line treatment with platinum and paclitaxel, were included in our analysis. After a median follow-up of 65 months, 150 patients had relapsed. Eight patients (5%) had isolated brain metastases. Patient and disease characteristics did not differ among patients who relapsed with isolated brain metastases and those with relapse outside the CNS. Median time to first disease relapse, overall survival, and survival after relapse did not differ significantly between patients with brain metastases and those with relapse outside the CNS. Two patients have died 6 and 12 months after the diagnosis of brain metastases, and 5 patients are alive 4-35 months after the diagnosis of isolated brain metastases. Three patients remain free of disease 4-18 months after treatment with radiotherapy and systemic chemotherapy for their CNS metastatic disease. Patients with isolated brain metastases have comparable survival to patients with relapse outside the CNS, and long-term remission can be achieved in some cases, provided that systemic chemotherapy is added to local treatment.

Brain Metastases from Epithelial Ovarian Cancer: A Review of the Literature

BACKGROUND

Brain metastases from epithelial ovarian cancer (EOC) are rare. This report is based on a review of the literature.

METHODS AND RESULTS

This review summarizes the incidence, clinical features, pathophysiology, and diagnostic evaluation of EOC. The section on current treatment includes a thorough evaluation of the literature, highlights controversies over treatment options, and provides insight into novel approaches. Current treatment options include surgical resection, whole-brain radiation therapy (WBRT), stereotactic radiosurgery, and chemotherapy. Corticosteroids and anticonvulsant medications are commonly used for the palliation of mass effects and seizures, respectively. In the reviewed series, a better outcome was seen following surgical resection and WBRT with or without chemotherapy for solitary and resectable brain metastases.

CONCLUSION

The prognosis for patients with brain metastases from EOC is poor. A better outcome might be obtained using multimodality therapy. Because of the small number of patients included in the reported studies, multicenter clinical trials are needed for further investigation in order to critically evaluate the clear benefit of these treatment options in selected patients.