Gamma-knife radiosurgery for the treatment of ovarian cancer metastatic to the brain

Gamma Knife radiosurgery for metastatic brain tumors from ovarian cancer: histopathological analysis of survival and local control. A Japanese multi-institutional cooperative and retrospective cohort study

OBJECTIVE

Brain metastasis is rare in ovarian cancer patients. The results of Gamma Knife radiosurgery (GKRS) for the treatment of patients with brain metastases from ovarian cancer were retrospectively analyzed to derive the efficacy and prognostic factors for survival and local tumor control. Further histopathological analysis was also performed.

METHODS

The authors retrospectively reviewed the medical records of 118 patients with 566 tumors who had undergone GKRS at the 10 GKRS institutions in Japan.

RESULTS

After the initial GKRS, the median overall survival time was 18.1 months. Multivariate analysis showed that uncontrolled primary cancer (p = 0.003) and multiple intracranial metastases (p = 0.034) were significant unfavorable factors. Ten patients died of uncontrolled brain metastases at a median of 17.1 months. The 6-, 12-, and 24-month neurological death rates were 3.2%, 4.6%, and 11.9%, respectively. The 6-, 12-, and 24-month neurological deterioration rates were 7.2%, 13.5%, and 31.4%, respectively. The 6-, 12-, and 24-month distant brain control failure rates were 20.6%, 40.2%, and 42.3%, respectively. Median tumor volume was 1.6 cm3 and marginal dose was 20 Gy. The 6-, 12-, and 24-month local tumor control rates were 97.6%, 95.2%, and 88.0%, respectively. Peritumoral edema (p = 0.043), more than 7-cm3 volume (p = 0.021), and prescription dose less than 18 Gy (p = 0.014) were factors that were significantly correlated in local tumor control failure. Eight patients had symptomatic radiation injury. The 6-, 12-, and 24-month GKRS-related complication rates were 3.3%, 7.8%, and 12.2%, respectively. Primary ovarian cancer was histopathologically diagnosed for 313 tumors in 69 patients. Serous adenocarcinoma was found in 37 patients and other types in 32 patients. Median survival times were 32.3 months for the serous type and 17.4 months for other types after initial GKRS. Patients with serous-type tumors survived significantly longer than patients with other types (p = 0.039). The 6-, 12-, and 24-month local tumor control rates were 100%, 98.8%, and 98.8%, respectively. Serous-type tumors were a significantly good prognosis factor for local tumor control after GKRS (p = 0.005).

CONCLUSIONS

This study established a relationship between the efficacy of GKRS treatment for brain metastases and the histological type of primary ovarian cancer. GKRS for ovarian cancer brain metastasis can provide satisfactory survival and local control, especially in cases of serous adenocarcinoma.

Association between Stereotactic Radiotherapy and Death from Brain Metastases of Epithelial Ovarian Cancer: a Gliwice Data Re-Analysis with Penalization

Background: Clinical datasets for epithelial ovarian cancer brain metastatic patients are usually small in size. When adequate case numbers are lacking, resulting estimates of regression coefficients may demonstrate bias. One of the direct approaches to reduce such sparse-data bias is based on penalized estimation. Methods: A re- analysis of formerly reported hazard ratios in diagnosed patients was performed using penalized Cox regression with a popular SAS package providing additional software codes for a statistical computational procedure. Results: It was found that the penalized approach can readily diminish sparse data artefacts and radically reduce the magnitude of estimated regression coefficients. Conclusions: It was confirmed that classical statistical approaches may exaggerate regression estimates or distort study interpretations and conclusions. The results support the thesis that penalization via weak informative priors and data augmentation are the safest approaches to shrink sparse data artefacts frequently occurring in epidemiological research.

Clinical Outcomes of Gamma Knife Radiosurgery for Metastatic Brain Tumors from Gynecologic Cancer : Prognostic Factors in Local Treatment Failure and Survival

Objective

Brain metastases in gynecologic cancer (ovarian, endometrial, and cervical cancer) patients are rare, and the efficacy of Gamma Knife Radiosurgery (GKRS) to treat these had not been evaluated. We assessed the efficacy of GKRS and prognostic factors for tumor control and survival in brain metastasis from gynecologic cancers.

Methods

This retrospective study was approved by the institutional review board. From May 1995 to October 2012, 26 women (mean age 51.3 years, range 27–70 years) with metastatic brain tumors from gynecologic cancer were treated with GKRS. We reviewed their outcomes, radiological responses, and clinical status.

Results

In total 24 patients (59 lesions) were available for follow-up imaging. The median follow-up time was 9 months. The mean treated tumor volume at the time of GKRS was 8185 mm³ (range 10–19500 mm³), and the median dose delivered to the tumor margin was 25 Gy (range, 10–30 Gy). A local tumor control rate was 89.8% (53 of 59 tumors). The median overall survival was 9.5 months after GKRS (range, 1–102 months). Age-associated multivariate analysis indicated that the Karnofsky performance status (KPS), the recursive partitioning analysis (RPA) classification, and the number of treated lesions were significant prognostic factors for overall survival (HR=0.162, p=0.008, HR=0.107, p=0.038, and HR=2.897, p=0.045, respectively).

Conclusion

GKRS is safe and effective for the management of brain metastasis from gynecologic cancers. The clinical status of the patient is important in determining the overall survival time.

Gamma knife radiosurgery for the treatment of gynecologic malignancies metastasizing to the brain: clinical article

Gynecologic malignancies represent some of the commonest causes of cancer in the female population. Despite their overall high prevalence, gynecologic malignancies have seldom been reported to metastasize to the brain. The incidence of gynecologic cancers spreading to the brain has been rising, and the optimal management of these patients is not well defined. A retrospective analysis of patients treated over the past ten years with gamma knife radiosurgery (GKRS) for metastatic gynecologic cancer to the brain was performed. Radiographic treatment response, tumor control, metastatic disease progression and survival data were analyzed. Eight patients with ovarian cancer, six patients with endometrial cancer and two separates who carried a diagnosis of cervical cancer or leiomyosarcoma harbored metastatic disease to the brain that was treated with GKRS. The median dose to the tumor margin was 20 Gy (range 10-22 Gy), and the median maximum radiosurgical dose was 31 Gy (range 16-52.9 Gy). Tumor control was achieved in all patients who had follow up imaging studies. Patients with ovarian cancer had prolonged median survival following GKRS compared to patients with endometrial cancer (22.3 vs 8.3 months, p = 0.02). The patient with cervical cancer survived 8 months following her GKRS in the setting of metastatic brain tumor progression, whereas the patient with leiomyosarcoma passed away within several weeks of treatment secondary to disseminated extracranial primary disease. GKRS is a safe and effective means of achieving intracranial tumor control for patients with gynecologic cancer that has spread to the brain.

Stereotactic radiotherapy in epithelial ovarian cancer brain metastases patients

BACKGROUND

In this report we present the results of the retrospective (survival and classification) analyses of possible prognostic factors prolonging survival in epithelial ovarian cancer brain metastases patients after stereotactic radiotherapy. We focus on a wide range of available predictors to establish survival in patients with a good health status and no more than three lesions.

METHODS

Two parallel statistical methods in survival analysis were used: classical and Bayesian methods to verify statistical results. To display the predicted and posterior survivals, classification trees were built.

RESULTS

From the initial set of prognostic factors, only four were established as statistically significant in multivariate regression. They were: survival to metastases to brain after epithelial ovarian cancer diagnosis, number of metastases at diagnosis, central nervous system radiotherapy prior to stereotactic radiotherapy, and interval to stereotactic radiotherapy after metastases diagnosis.

CONCLUSIONS

When considering evidence-based standards of treatment of patients suffering from epithelial ovarian cancer brain metastases, the established clinical factors are suggested to be prognostic.

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.

Stereotactic radiosurgical treatment of brain metastasis of primary tumors that rarely metastasize to the central nervous system

We evaluated the local control of gamma knife stereotactic radiosurgery (GKSRS) in the treatment of cerebral metastases from primary tumors that rarely metastasize to the central nervous system (CNS). There is little published data on this subject with very few series on specific primary tumors. We present our experience treating these lesions with GKSRS combined with a review of the salient literature. A retrospective study of 36 patients who collectively underwent 44 GKSRS procedures for CNS metastatic disease was undertaken. Our series includes four patients with sarcoma, two with prostate cancer, three with thyroid cancer, five with endometrial cancer, seven with ovarian cancer, two with cervical cancer, six with esophageal cancer, two with bladder cancer, one with liver cancer, one with pancreatic cancer, and three with testicular cancer. With 44 gamma knife sessions treating 74 tumors, 63 tumors showed no radiographic evidence of progression, and 13 tumors demonstrated radiographic progression between one and 12 months after gamma knife treatment. In six patients in the population, further treatment with GKSRS was necessary due to enlargement of untreated lesions or new metastatic disease. GKSRS for uncommon CNS metastases is appears to be efficacious in controlling the treated tumor. The majority of tumors treated in our study did not progress post gamma knife.

Changes in the management and outcome of central nervous system involvement from ovarian cancer since 1994

OBJECTIVE

To identify differences in the management and outcome of patients with central nervous system metastases from epithelial ovarian cancer.

METHODS

The clinical and pathologic characteristics, treatment, and outcome of 23 patients with brain metastases from epithelial ovarian cancer who were treated during 1982-1994 were compared with those of 20 patients treated during 1995-2010 at the same center.

RESULTS

No differences were found in terms of primary tumor characteristics, time interval from ovarian cancer diagnosis to brain involvement diagnosis, sites of metastasis, and presence of extracranial disease. The main difference between the 2 groups was the therapeutic approach. During 1982-1994, most patients received radiotherapy only, whereas most patients during 1995-2010 underwent surgical resection followed by radiotherapy and/or chemotherapy. The duration of survival during 1982-1994 was 5 months, which was significantly shorter than the duration of survival (18 months) during 1995-2010.

CONCLUSION

An aggressive multimodal treatment approach might prolong the survival of patients with brain involvement from ovarian cancer.

Clinical and pathological characteristics of brain metastasis resected after failed radiosurgery

OBJECTIVE

This study evaluates the tumor histopathology and clinical characteristics of patients who underwent resection of their brain metastasis after failed gamma knife radiosurgery.

METHODS

This study was a retrospective review from a prospective database. A total of 1200 brain metastases in 912 patients were treated by gamma knife radiosurgery during a 7-year period. Fifteen patients (1.6% of patients, 1.2% of all brain metastases) underwent resective surgery for either presumed tumor progression (6 patients) or worsening neurological symptoms associated with increased mass effect (9 patients). Radiographic imaging, radiosurgical and surgical treatment parameters, histopathological findings, and long-term outcomes were reviewed for all patients.

RESULTS

The mean age at the time of radiosurgery was 57 years (age range, 32-65 years). Initial pathological diagnoses included metastatic non-small cell lung carcinoma in 8 patients (53%), melanoma in 4 patients (27%), renal cell carcinoma in 2 patients (13%), and squamous cell carcinoma of the tongue in 1 patient (7%). The mean time interval between radiosurgery and surgical extirpation was 8.5 months (range, 3 weeks to 34 months). The mean treatment volume for the resected lesion at the time of radiosurgery was 4.4 cm(3) (range, 0.6-8.4 cm(3)). The mean dose to the tumor margin was 21Gy (range, 18-24 Gy). In addition to the 15 tumors that were eventually resected, a total of 32 other metastases were treated synchronously, with a 78% control rate. The mean volume immediately before surgery for the 15 resected lesions was 7.5 cm(3) (range, 3.8-10.2 cm(3)). Histological findings after radiosurgery varied from case to case and included viable tumor, necrotic tumor, vascular hyalinization, hemosiderin-laden macrophages, reactive gliosis in surrounding brain tissue, and an elevated MIB-1 proliferation index in cases with viable tumor. The mean survival for patients in whom viable tumor was identified (9.4 months) was significantly lower than that of patients in whom only necrosis was seen (15.1 months; Fisher's exact test, P < 0.05).

CONCLUSION

Radiation necrosis and tumor radioresistance are the most common causes precipitating a need for surgical resection after radiosurgery in patients with brain metastasis.

Clinical potential of mucins in diagnosis, prognosis, and therapy of ovarian cancer

Knowledge of mucins and their multiple roles in various normal and pathological processes has improved greatly in the past two decades. Mucins belong to a family of glycoproteins characterised by densely O-glycosylated repetitive domains and expressed by various surface epithelial cells. Altered expression of mucins is present in various diseases, including cancer. Ovarian cancer is the sixth most common cancer worldwide and the seventh leading cause of cancer-related deaths in women. The most common ovarian cancer is epithelial ovarian carcinoma, which is characterised by few early symptoms, widespread peritoneal dissemination, and ascites at advanced stages that result in poor prognosis. After diagnosis, 5 year survival is only 35-45%. Therefore, improved strategies for early diagnosis and treatment are needed. Because of the surface epithelial origin of epithelial ovarian cancer, mucins are obvious biomolecules for investigation as markers for early diagnosis and as therapeutic targets. We discuss the potential role and clinical usefulness of mucins in early diagnosis, prognosis, and treatment of ovarian cancer.

Prognostic factors associated with brain metastases from epithelial ovarian carcinoma

Brain metastasis from epithelial ovarian carcinoma (EOC) is managed by a multimodal treatment approach. Thus, to determine the prognostic factors associated with this situation is important for management decisions regarding the type of treatment and aggressiveness of treatment. From 1995 to 2005, 13 patients with brain metastases resulting from EOC underwent treatment at Samsung Medical Center. We retrospectively reviewed the medical records to determine prognostic factors and to evaluate treatment outcome. The median age at diagnosis for primary ovarian carcinoma and brain metastasis was 52 and 55 years, respectively. Median interval to brain metastases was 28 months after the diagnosis of EOC. At the time of analysis, nine patients had died of disease. The median survival from brain relapse was 7 months. A Karnofsky performance status of 70 or higher, primary control, solitary brain lesions, recursive partitioning analysis (RPA) class, and treatment modality including gamma-knife radiosurgery (GKRS) were related to survival on univariate analyses. Multivariate analysis showed that treatment modality including GKRS was a more important prognostic factor than RPA class (P= 0.04). This small series demonstrated that GKRS can be a valuable modality for the management of brain metastasis in patients with EOC. Therefore, a better outcome can be achieved by choosing GKRS in their treatments in selected patients.

Ovarian cancer metastatic to the breast

BACKGROUND

Metastatic ovarian cancer to the breast should be considered in the differential diagnosis for gynecologic cancer patients with a breast tumor. Despite early detection and treatment, the long-term prognosis for these patients is poor.

CASES

We present three ovarian cancer patients who developed metastatic ovarian cancer to the breast. All patients were heavily pre-treated prior to the development of metastatic disease. Currently, one patient is alive at 64 months following initial detection of her metastatic disease to the breast. The second and third patients are also alive for 30 and 3 months subsequent to their diagnosis of metastatic disease.

CONCLUSION

Although metastatic ovarian cancer to the breast following treatment for ovarian cancer is rare and associated with a poor prognosis, oncology physicians should be prepared to contend with disease metastatic to the breast. Additional investigation into the efficacy of surgery and novel chemotherapy agents is warranted.

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.