Central nervous system metastases in patients with ovarian carcinoma. A report of 23 cases and a literature review

Extracellular ATP/P2X7 receptor, a regulatory axis of migration in ovarian carcinoma-derived cells

ATP is actively maintained at high concentrations in cancerous tissues, where it promotes a malignant phenotype through P2 receptors. In this study, we first evaluated the effect of extracellular ATP depletion with apyrase in SKOV-3, a cell line derived from metastatic ovarian carcinoma. We observed a decrease in cell migration and an increase in transepithelial electrical resistance and cell markers, suggesting a role in maintaining a mesenchymal phenotype. To identify the P2 receptor that mediated the effects of ATP, we compared the transcript levels of some P2 receptors and found that P2RX7 is three-fold higher in SKOV-3 cells than in a healthy cell line, namely HOSE6-3 (from human ovarian surface epithelium). Through bioinformatic analysis, we identified a higher expression of the P2RX7 transcript in metastatic tissues than in primary tumors; thus, P2X7 seems to be a promising effector for the malignant phenotype. Subsequently, we demonstrated the presence and functionality of the P2X7 receptor in SKOV-3 cells and showed through pharmacological approaches that its activity promotes cell migration and contributes to maintaining a mesenchymal phenotype. P2X7 activation using BzATP increased cell migration and abolished E-cadherin expression. On the other hand, a series of P2X7 receptor antagonists (A438079, BBG and OxATP) decreased cell migration. We used a CRISPR-based knock-out system directed to P2RX7. According to the results of our wound-healing assay, SKOV3-P2X7KO cells lacked receptor-mediated calcium mobilization and decreased migration. Altogether, these data let us propose that P2X7 receptor is a regulator for cancer cell migration and thus a potential drug target.

Iatrogenic Leptomeningeal Carcinomatosis Following Craniotomy for Resection of Metastatic Serous Ovarian Carcinoma: A Systematic Literature Review and Case Report

Metastasis of ovarian carcinoma to the central nervous system occurs in <2% of cases and classically localizes within the brain parenchyma. Moreover, leptomeningeal spread of these tumors is an exceedingly rare phenomenon. Here, we conduct a systematic review of the current literature on the natural history, treatment options, and proposed pathogenic mechanisms of leptomeningeal carcinomatosis in ovarian carcinoma. We also report a case of a 67-year-old female with stage IV metastatic ovarian serous carcinoma initially confined to the peritoneal cavity with a stable disease burden over the course of three years. Follow-up imaging demonstrated an intracranial lesion, which was resected via craniotomy, and pathology was consistent with the original diagnosis. Three months after surgery, she developed rapidly progressive dizziness, generalized weakness, fatigue, and ataxia. Repeat MRI demonstrated interval development of extensive and diffusely enhancing dural nodularity, numerous avidly enhancing supratentorial and infratentorial lesions, enhancement of the bilateral trigeminal nerves, internal auditory canals, and exit wound from the surgical site into the posterior aspect of the right-sided neck musculature consistent with diffuse leptomeningeal dissemination. The present case highlights that leptomeningeal dissemination of ovarian carcinoma is a potential yet rare consequence following surgical resection of an ovarian parenchymal metastasis. Progressive clinical symptomatology that develops postoperatively in this patient population should prompt urgent workup to rule out leptomeningeal disease and an expedited radiation oncology consultation if identified.

Brain Metastases from Ovarian Cancer: Current Evidence in Diagnosis, Treatment, and Prognosis

With this review, we provide the state of the art concerning brain metastases (BMs) from ovarian cancer (OC), a rare condition. Clinical, pathological, and molecular features, treatment options, and future perspectives are comprehensively discussed. Overall, a diagnosis of high-grade serous OC and an advanced disease stage are common features among patients who develop brain metastases. BRCA1 and BRCA2 gene mutations, as well as the expression of androgen receptors in the primary tumor, are emerging risk and prognostic factors which could allow one to identify categories of patients at greater risk of BMs, who could benefit from a tailored follow-up. Based on present data, a multidisciplinary approach combining surgery, radiotherapy, and chemotherapy seem to be the best approach for patients with good performance status, although the median overall survival (<1 year) remains largely disappointing. Hopefully, novel therapeutic avenues are being explored, like PARP inhibitors and immunotherapy, based on our improved knowledge regarding tumor biology, but further investigation is warranted.

Cauda equina syndrome in an ovarian malignant-mixed müllerian tumor with leptomeningeal spread

Leptomeningeal metastasis is extremely rare in patients with ovarian cancer, but should be considered in patients presenting with neurologic deficits such as cauda equine syndrome. Given its poor prognosis and lack of data currently on management, additional studies are needed to optimize treatment regimens and improve outcomes.

Treatment Results and Prognostic Factors of Brain Metastases From Ovarian Cancer: A Single Institutional Experience of 56 Patients

OBJECTIVES

The most appropriate treatments for brain metastases from ovarian cancer have not been established mainly because of its rarity. The objective of this study was to describe clinical results of treatment and prognostic factors of patients with brain metastases from ovarian cancer treated at a single institution.

MATERIALS AND METHODS

We retrieved information from the electronic medical records of 56 consecutive patients (2.8%) with brain metastases, from a total of 2008 patients with ovarian cancer. Endpoints were the pattern of treatment failure, progression-free survival, and overall survival (OS).

RESULTS

Radiation was the most common initial treatment for brain metastases (59%), followed by surgery (23%). The median progression-free survival was 9.8 months. Radiological progression was confirmed in 20 patients: 7 had leptomeningeal carcinomatosis (37%), 8 had local recurrence, and 5 had distant recurrence. Median OS was 11.25 months, and the 1-year OS rate was 48.2%. Patients received surgery for single metastasis as initial treatment showed median OS of 24.1 months, which was significantly prolonged compared with the other patients (P = 0.0002). Of the 48 patients who died, 29 (60%) died of systemic disease and 7 (15%) died of central nervous system progression. Karnofsky Performance Status greater than or equal to 70, control of systemic cancer, serous histology, and surgery for brain metastases were associated with improved OS in multivariable analysis (P < 0.05).

CONCLUSIONS

Surgical resection for single or symptomatic brain metastases from ovarian cancer prolonged OS significantly. Multimodality treatment, including control of systemic cancer, appeared to be an important factor in prolonging OS.

Efficacy of gamma knife radiosurgery in brain metastases of primary gynecological tumors

OBJECTIVE

Gynecological brain metastases (BM) are rare and usually develop as part of widespread disseminated disease. Despite treatment, the majority of these patients do not survive > 1 year due to advanced extracranial disease. The use of Gamma Knife Radiosurgery (GKRS) for gynecological BM is not well known. The goal of this study is to evaluate the efficacy of GKRS for gynecological BM.

METHODS

We performed a retrospective study of patients with gynecological BM who underwent GKRS between 2002 and 2015. A total of 41 patients were included. Outcome measures were local tumor control (LC), development of new BM and/or leptomeningeal disease, overall intracranial progression free survival (PFS) and survival.

RESULTS

LC was 100%, 92%, 80%, 75% and 67% at 3, 6, 9, 12 and 15 months, respectively. PFS was 90%, 61%, 41%, 23% and 13% at 3, 6, 9, 12 and 15 months, respectively. During follow-up (FU), 18 (44%) patients had intracranial progression. Distant BM occurred in 29% of the patients. Local recurrence and distant recurrence occurred after a mean FU time of 15.5 (2.6-71.9) and 11.4 (2-40) months, respectively. Thirty-one (76%) patients died due to extracranial tumor progression and only 2 (5%) patients died due to progressive intracranial disease. The overall mean survival from time of GKRS was 19 months (1-109). The 6-month, 1-year, and 2-year survival rate from the time of GKRS were 71%, 46%, and 22%, respectively.

CONCLUSION

GKRS is a good treatment option for controlling gynecological BM. As most patients die due to extracranial tumor progression, their survival might improve with better systemic treatment options in addition to GKRS.

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.

Brain metastases in patients with EOC: Clinico-pathological and prognostic factors. A multicentric retrospective analysis from the MITO group (MITO 19)

BACKGROUND

Brain metastases (BM) from epithelial ovarian cancer (EOC) are considered a rare and unfavourable event. There is no consensus regarding the best management of these patients.

METHODS

A multicenter retrospective analysis of patients with BM from EOC treated between 1997 and 2014 in 18 institutions of the MITO (Multicenter Italian Trials in Ovarian cancer) group was conducted. Univariate and multivariate analysis were performed.

RESULTS

A total of 174 women were identified as having BM from EOC. The median time interval between primary diagnosis of EOC and occurrence of BM was 26months (range 2-129months). The median overall survival from primary EOC diagnosis was 48months (95% CI 39.5-56.4months) and from diagnosis of BM was 12months (95% CI 9.6-14.3months). The majority of enrolled women (81.7%) were classified as sensitive to platinum-based chemotherapy. Four variables were significantly associated with poor overall survival in multivariate analysis: multiple BM [HR: 1.86 (95% CI: 1.22-2.84)], presence of extracranial disease [HR: 1.77 (95% CI: 1.11-2.83)] age [HR: 1.74 (95% CI: 1.17-2.59)], and monotherapy [HR: 2.57 (95% CI: 1.64-3.86)]. On the contrary, residual tumor at primary surgery, FIGO stage at primary diagnosis and platinum sensitivity were found to have no significant impact on survival from diagnosis of brain lesions.

CONCLUSIONS

Our results suggest that BM is a rare and late manifestation of EOC, with a 12-month life-span expectation. Multiple approach is a positive independent prognostic factor and should be proposed to carefully selected patients.

BRCA2-positive spinal intramedullary ovarian metastatic disease: case report

BACKGROUND CONTEXT

Ovarian cancer is the fourth leading cause of cancer death in women, but advances in treatment have led to longer survival among these patients. Tied to these advances and increased survival, however, have been new patterns of metastatic spread.

PURPOSE

The authors discuss the management and surgical decision making in patients with intramedullary ovarian metastatic disease using a case illustration and relevant literature.

STUDY DESIGN/SETTING

A case report was used.

METHODS

The authors describe a case of a 59-year-old woman with Breast Cancer gene (BRCA) 2-positive ovarian cancer who developed progressive myelopathy from a T10 to T11 intramedullary metastatic lesion.

RESULTS

The patient underwent a standard open T10-T11 laminectomy for intramedullary tumor resection. Intraoperative ultrasound was used to direct the dural opening over the lesion. After a posterior midline myelotomy, microsurgical dissection revealed the intramedullary tumor with a discolored fibrous capsule, which was carefully dissected off of the spinal tracts, and a gross total resection was achieved. Postoperative magnetic resonance imaging at 6 months demonstrated no evidence of residual or recurrent intramedullary tumor. The patient underwent adjuvant external beam radiation to the thoracic spine but succumbed to her primary disease 1 year after surgery.

CONCLUSION

Although central nervous system involvement of ovarian cancer confers a poor prognosis, patients presenting with a solitary lesion and neurologic deficit may benefit from surgical resection followed by steroids and radiation therapy, especially when tissue diagnosis is necessary.

A clinical analysis of brain metastasis in gynecologic cancer: a retrospective multi-institute analysis

This study analyzes the clinical characteristics of the brain metastasis (BM) of gynecologic cancer based on the type of cancer. In addition, the study examines the factors influencing the survival. Total 61 BM patients of gynecologic cancer were analyzed retrospectively from January 2000 to December 2012 in terms of clinical and radiological characteristics by using medical and radiological records from three university hospitals. There were 19 (31.1%) uterine cancers, 32 (52.5%) ovarian cancers, and 10 (16.4%) cervical cancers. The mean interval to BM was 25.4 months (21.6 months in ovarian cancer, 27.8 months in uterine cancer, and 33.1 months in cervical cancer). The mean survival from BM was 16.7 months (14.1 months in ovarian cancer, 23.3 months in uterine cancer, and 8.8 months in cervical cancer). According to a multivariate analysis of factors influencing survival, type of primary cancer, Karnofsky performance score, status of primary cancer, recursive partitioning analysis class, and treatment modality, particularly combined therapies, were significantly related to the overall survival. These results suggest that, in addition to traditional prognostic factors in BM, multiple treatment methods such as neurosurgery and combined chemoradiotherapy may play an important role in prolonging the survival for BM patients of gynecologic cancer.

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.

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.

Ovarian small cell carcinoma complicated by carcinomatous meningitis

Meningeal metastasis is rare in the clinical course of ovarian carcinoma and its prognosis is extremely poor. We experienced a case of carcinomatous meningitis from metastatic ovarian small cell carcinoma. A 33-year-old woman with atypical genital bleeding, was diagnosed with a right ovarian tumor and referred to our department. She underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and lymphadenectomy. It was an optimal debulking surgery. She was diagnosed with ovarian carcinoma classified as Stage IIIc according to the Féderation Internationale de Gynécologie et d'Obstétrique classification system. Histological findings showed small cell carcinoma of the pulmonary type. The tumor was bilateral with paraaortic lymph node involvement. The patient was treated with irinotecan and cisplatin (CPT-P therapy). After 4 courses of CPT-P therapy, multiple liver metastases and Virchow's lymph node metastases were found. She was treated with amrubicin as a second-line chemotherapy, but the treatment was ineffective. Five months after surgery, the patient complained of severe headache and nausea. Lumbar puncture was performed and cytology was positive. Magnetic resonance brain imaging indicated meningeal thickening. The patient was diagnosed with meningeal metastasis and received 19-Gy whole cranial irradiation. In spite of these treatments, her disease progressed rapidly and she was often drowsy. She died of aspiration pneumonia 6 months after surgery.

Epithelial-mesenchymal transition in ovarian carcinoma

Ovarian cancer is the most lethal gynecologic malignancy, with the majority of patients dying within 5 years of diagnosis. This poor survival of patients diagnosed with this malignancy is attributed to diagnosis at advanced stage, when the tumor has metastasized, and to chemotherapy resistance, either primary or developing along tumor progression. However, ovarian carcinomas, constituting the vast majority of ovarian cancers, additionally have unique biology, one aspect of which is the ability to co-express epithelial and mesenchymal determinants. epithelial–mesenchymal transition (EMT), a physiological process by which mesenchymal cells are formed and migrate to target organs during embryogenesis, is involved in cancer cell invasion and metastasis. However, these changes do not fully occur in ovarian carcinoma, and are even reversed in tumor cells present in malignant peritoneal and pleural effusions. This review summarizes current knowledge in this area, including the characteristics of EMT related to adhesion, transcriptional regulation and chemoresistance, and their clinical relevance, as well as the recently observed regulation of EMT by microRNA.

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.

Leptomeningeal carcinomatosis from ovarian cancer

Ovarian cancer is the most common cause of mortality among women with gynecologic malignancies and the fifth leading cause of death in all women. It usually spreads locally; hematogenous dissemination is rare, most often involving the liver and lungs. Cerebral metastases are reported in less than 2% of cases and tend to localize to the parenchyma, usually in the cerebrum. Leptomeningeal involvement is exceptionally rare. We report a case of a woman with metastatic ovarian cancer who developed leptomeningeal carcinomatosis while receiving systemic chemotherapy. We also provide an extensive review of the existing literature on neoplastic meningitis from ovarian cancer.

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.

Leptomeningeal metastasis from ovarian carcinoma successfully treated by the intraventricular administration of methotrexate

A 60-year-old woman with a history of ovarian carcinoma and complaining of gait instability, dizziness, nausea, and a right temporal headache visited a neurologist. A diagnosis of leptomeningeal metastasis was made, based on the results of a cerebrospinal fluid examination. After the administration of intrathecal methotrexate, her neurological complaints disappeared. An Ommaya intraventricular reservoir was inserted, and methotrexate administration was continued for 11 months, until another recurrence was found in her pelvis. Although uncommon, the possibility of leptomeningeal metastasis from ovarian carcinoma should be considered; in such cases, treatment with intraventricular methotrexate may be effective and feasible and should be considered as a treatment strategy.

Vascular endothelial growth factor stimulates organ-specific host matrix metalloproteinase-9 expression and ovarian cancer invasion

Vascular endothelial growth factor (VEGF) and matrix metalloproteinases (MMP) regulate each other, contributing to tumor progression. We have previously reported that MMP9 induces the release of tumor VEGF, promoting ascites formation in human ovarian carcinoma xenografts. The aim of this study was to investigate whether tumor-derived VEGF regulated the expression of gelatinase by the stroma, influencing the invasive properties of ovarian tumors. Tumor variants derived from 1A9 human ovarian carcinoma, stably expressing VEGF(121) in the sense (1A9-VS-1) and antisense orientations (1A9-VAS-3), were used. In vivo, zymographic analysis of tumors from 1A9-VS-1 implanted in the peritoneal cavity of nude mice showed higher levels of gelatinases, particularly murine MMP9, indicating that VEGF stimulates host expression of the matrix-degrading enzyme. Murine MMP9 expression was also high in the ovaries of mice bearing 1A9-VS-1 tumors. The effect on host MMP9 activity was organ-specific. The levels of host pro-MMP9 in ovaries correlated with the plasma levels of tumor VEGF and with the selective invasion of the ovaries. Induction of host MMP9 expression in tumors and ovaries was independent of the site of tumor growth as it was seen in mice carrying both intraperitoneal and subcutaneous tumors. The anti-VEGF antibody bevacizumab (Avastin) inhibited MMP9 expression and tumor invasion in the ovaries of mice bearing 1A9-VS-1 tumors. These findings point to a complex cross-talk between VEGF and MMPs in the progression of ovarian tumor and suggest the possibility of using VEGF inhibitors to affect MMP-dependent tumor invasion.

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 associated with carcinomatous meningitis: a case report and review of the literature

We report the case of a 62-year-old patient who developed a carcinomatous meningitis while on second-line chemotherapy for ovarian cancer. Cytologic analyses confirmed that carcinomatous cells of ovarian origin were present in cerebrospinal fluid. Carcinomatous meningitis is a very rare event in the natural history of ovarian carcinoma. We discuss the specificity of our case in the light of the literature. In addition, we present some relevant radiologic and pathologic documents illustrating this rare entity.

Epithelial–mesenchymal interconversions in normal ovarian surface epithelium and ovarian carcinomas: An exception to the norm

Cancer that arises from the ovarian surface epithelium (OSE) accounts for approximately 90% of human ovarian cancer, and is the fourth leading cause of cancer-related deaths among women in developed countries. The pathophysiology of epithelial ovarian cancer is still unclear because of the poor understanding of the complex nature of its development and the unusual mechanism(s) of disease progression. Recent studies have reported epithelial-mesenchymal transition (EMT) in cultured OSE and ovarian cancer cell lines in response to various stimuli, but our understanding of the importance of these observations for normal ovarian physiology and cancer progression is not well established. This review highlights the current literature on EMT-associated events in normal OSE and ovarian cancer cell lines, and discusses its implication for normal ovarian function as well as acquisition of neoplastic phenotypes. The pathological changes in OSE in response to EMT during neoplastic transformation and the contribution of hormones, growth factors, and cytokines that initiate and drive EMT to sustain normal ovarian function, as well as cancer development and progression are also discussed. Finally, emphasis is placed on the clinical implications of EMT and potential therapeutic opportunities that may arise from these observations have been proposed.

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.

Brain metastases from epithelial ovarian cancer

Brain metastasis from epithelial ovarian cancer is uncommon. We studied the presentation, treatment, and prognosis of brain metastasis in a single institution. A retrospective review of clinical details kept in the computer database of gynecologic oncology services in a tertiary institution between 1993 and 2003 was done. A Medline search for English publications on brain metastasis from epithelial ovarian cancer was performed from 1966 to 2003. The study period included 605 patients, and 4 (0.66%) patients developed brain metastases. The patients were usually well, until they presented with hemiparesis. The median primary treatment to brain metastasis interval was 16.5 months. Three out of four cases had multiple brain metastases, and all had small-volume extracranial tumor relapses. Serum CA125 measurement was not reliable in the screening for brain metastasis. The median survival after brain metastasis was 19.5 months. Single brain metastasis can be treated with surgery. Our experience supports the prevalent published opinion that all other cases should be considered for combined radiotherapy and surgery or radiotherapy and chemotherapy. Surveillance of tumor recurrence with serum CA125 monitoring does not predict brain metastasis, which carries a poor prognosis. The best mode of management of these patients is yet to be determined. Large study with multicenter participation to establish the standard treatment is urgently needed.

Multiple cerebral and leptomeningeal metastases from ovarian carcinoma: unusual early presentation

Although virtually any systemic malignancy is capable of metastasizing to the brain, ovarian carcinoma, one of the more common female genital malignancies, is one of the rarer forms of brain metastases. In general, the outcome for ovarian carcinoma with brain metastases is extremely poor as most of these patients have widespread lesions elsewhere. This report describes the first known case of multiple cerebral and leptomeningeal metastases as the initial manifestation of ovarian carcinoma in a 41-year old woman who presented with a one-week history of headache, vomiting and confusion. CT scan of the brain was unremarkable, but lumbar puncture revealed atypical cells in the CSF. MRI scan of the brain showed multiple small enhancing lesions. Craniotomy for excision of one of these lesions demonstrated metastatic adenocarcinoma. A large ovarian tumour identified on pelvic CT scan was resected and the patient subsequently received chemotherapy and radiotherapy. Unfortunately she continued to decline and died within six months. Unlike primary tumours such as malignant melanoma, ovarian carcinoma does not have a predilection for the central nervous system (CNS), but the rare instances with CNS involvement occur at an advanced stage of the disease. Once the CNS is involved, the outcome is abysmal, even with multimodality therapy. It is extremely unusual for ovarian carcinoma to present with multiple CNS involvement.

Serous carcinoma of the ovary and peritoneum with metastases to the breast and axillary lymph nodes: a potential pitfall

Metastasis of ovarian or peritoneal serous carcinoma to the breast and/or axillary lymph nodes is a rare event. Nevertheless, its recognition and distinction from mammary carcinoma are of great clinical importance because the treatment and prognosis differ significantly. Eighteen cases of ovarian or peritoneal serous carcinoma metastatic to the breast and/or axillary LNs from a 14-year period (1990-2003) were retrieved from our files. Clinical information was obtained from the patients' charts. The age of the patients ranged from 21 to 67 years (median, 55 years). The primary tumors included 14 ovarian serous carcinomas (11 high grade and 3 low grade; 2 of the low-grade tumors presented as serous tumors of low malignant potential and recurred as low-grade serous carcinoma) and 4 peritoneal serous carcinomas (3 high grade and 1 low grade). Of the ovarian neoplasms, 1 was stage I and 10 were stage III tumors; the breast and/or axillary lymph node metastases were discovered on average 30 months after presentation (range, 7-135 months). Three of the ovarian serous carcinomas were stage IV tumors; in 1 case, there were axillary lymph node metastases at initial presentation; and in 2 cases, breast and/or axillary lymph node metastases developed at 18 and 102 months. Two of the 4 patients with peritoneal serous carcinoma presented with stage IV disease, having synchronous breast and axillary lymph node metastases; the other 2 patients developed them at 11 and 16 months after presentation. Four patients had multiple breast lesions and 8 patients had a single metastasis. In 4 cases, the breast metastases were initially interpreted as infiltrating ductal carcinoma. The remaining 6 patients had axillary lymph node involvement only. The metastases in 17 of the cases had papillary features, with psammoma bodies present in 4. Immunoperoxidase studies for GCDFP-15 and WT-1 were performed in 4 cases; all 4 were positive for WT-1 and negative for GCDFP-15. Follow-up was available for 17 patients, with 7 patients known to be dead from disease (survival range, 2-31 months) after the development of metastatic disease to the breast or axillary lymph nodes. Ten patients were alive with disease at their last follow-up, which ranged from 1 to 30 months after the breast or axillary LN metastasis developed. Metastases to the breast or axillary lymph nodes from ovarian and/or peritoneal serous carcinomas are uncommon. Most of the patients in whom metastatic disease develops have a known history of advanced stage ovarian or peritoneal carcinoma. Breast and/or axillary LN involvement at initial presentation can occur but is rare. Differentiation between metastatic and primary tumors of the breast is of great importance because treatment and prognosis differ significantly. Clinical history, the presence of papillary architecture, and WT-1 expression are useful in establishing the correct diagnosis.

Clinical features of hepatic metastasis in patients with ovarian cancer

The purpose of this study was to investigate the clinical features of hepatic metastasis in patients with epithelial ovarian cancer. From 1998 to 2002, all women with hepatic metastasis from ovarian cancer were identified at the University of Bari. Twenty-nine patients identified included one having stage IIC, one stage IIIA, two stage IIIB, 17 stage IIIC, and eight stage IVB. Eight women had hepatic metastasis at the time of the diagnosis of ovarian cancer (group I), 10 patients had hepatic metastasis as first recurrence (group II), and 11 (group III) as a second relapse. The median survival from the time of liver metastasis diagnosis was 19 months in group I patients, 24 months in group II patients, and 10 months in group III patients. No statistical differences in survival were seen among the three groups (P = 0.7). Cell type, performance status at the time of the primary tumor diagnosis, number of hepatic lesions, the presence of other sites of disease at the time of hepatic metastasis, and platinum-based chemotherapy were significantly related to survival. Better performance status, serous cell-type tumor, single hepatic lesion, the absence of other sites of disease, and platinum-based chemotherapy are good prognostic factors.

Solitary cerebral metastases from ovarian epithelial carcinoma: 11 cases

Ovarian cancer is quite common in women, but brain metastases from ovarian cancer are considered rare. Eleven patients with solitary cerebral metastasis from ovarian epithelial carcinoma were treated at the Neurosurgical Department of University of Rome La Sapienza, between 1980 and 2000. We treated all of the 11 patients by surgical en bloc removal and by postoperative radiotherapy and chemotherapy. Mean survival was 28 months, and the cause of death was recurrence of the systemic disease in all cases. Multimodal treatment by surgery, radiation and chemotherapy is the best choice of treatment and leads to a median survival of about 20 months.

Role of surgical resection for lung, liver, and central nervous system metastases in patients with gynecological cancer: a literature review

Many reports of ovarian, cervical, and uterine cancers metastatic to lung, liver, and brain have been published. A fewer number of them focused on the surgical treatment for these patients. We reviewed the published literature, regarding surgical management of metastatic disease in patients with gynecological cancer. Some prognostic factors in the patients with metastatic lesions from these three different cancers were found in common. Favorable prognostic factors for a prolonged survival were good performance status of the patients, long disease-free interval, absence of other systemic disease, and the resectability, preferably with a clear margin. These factors should be considered as the criteria for surgery. In well-selected patients, survival could be extended from the surgical procedure with minimal complications. Other types of treatment such as radiation therapy or chemotherapy could also be given in conjunction with surgery, depending on tumor type and disease status of the primary cancer, other systemic diseases, and residual metastatic lesions after surgery.

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

BACKGROUND

Brain represents a rare site of metastasis in patients with epithelial ovarian carcinoma (EOC).

CASE REPORT

We observed a case of multiple brain metastases in an EOC patient after complete response of a pelvic recurrence to platinum/paclitaxel chemotherapy. Complete response of brain metastases was observed after whole brain radiotherapy and subsequent chemotherapy by combination of cisplatin and gemcitabine. Three subsequent recurrences of brain metastases were controlled by re-treatment by the combination of 5-fluorouracil, cisplatin and gemcitabine.

METHODS

Because of limited information on the outcome of EOC brain metastases in reported case series, a pooled analysis of the published reports in patients with EOC brain metastases was performed. Data were extracted from 46 reports that contained sufficient details on 189 individual patients. The survival was analyzed by the Kaplan-Meier method. Univariate and multivariate analyses were performed by the log-rank test and Cox method, respectively.

RESULTS

The most favorable outcome was observed in patients treated by surgery combined with radiotherapy and/or chemotherapy. The survival was significantly better in reports describing only one or two cases, in patients diagnosed after 1992, in patients who received therapy in addition to symptomatic treatment, in patients treated by radiotherapy, chemotherapy and surgery, in patients without extracranial metastases and with single brain metastases. On multivariate analysis, the absence of extracranial metastases, treatment by chemotherapy, surgery and radiotherapy were independent positive predictors of survival.

CONCLUSIONS

EOC brain metastases are responsive to chemotherapy. An aggressive multidisciplinary therapeutic approach including chemotherapy may lead to prolonged survival.

Effusion cytology in ovarian cancer: new molecular methods as aids to diagnosis and prognosis

Carcinoma of the ovary is the leading cause of death from gynecologic cancer in western countries. Ovarian carcinoma is commonly associated with the accumulation of fluid that contains malignant cells in the peritoneal and pleural cavities. This article details the current knowledge regarding the diagnostic and biologic characteristics of ovarian carcinoma cells in effusions, and the genotypic and phenotypic differences between solid primary tumors and metastatic lesions. Finally, we present a new approach, by which the analysis of fresh frozen viable cells allows us to study in vivo the links between expression and activity of extracellular mediators, membrane receptors, intracellular signaling, and transcription factors, and their potential therapeutic and prognostic significance.

Surgical resection of solitary brain metastasis from ovarian carcinoma: an analysis of 22 cases

OBJECTIVE

Central nervous system (CNS) involvement is considered an uncommon complication in patients with ovarian carcinoma. The aim of this study was to evaluate prognostic factors for survival following surgical resection of brain metastases in patients with ovarian carcinoma.

METHODS

A retrospective chart review was conducted on 22 patients who had been submitted to neurosurgical resection of a solitary brain metastasis from ovarian carcinoma.

RESULTS

Eighteen lesions were cerebral, 4 were cerebellar. CNS was the only site of disease in 9 patients, 9 patients had CNS and abdominopelvic disease, and 4 also had concomitant extraperitoneal dissemination. Following surgery, 17 received whole-brain radiotherapy and 5 received systemic chemotherapy. Median survival from diagnosis of cerebral metastasis for the entire series was 16 months (range, 4-41 months). Extracranial disease at the time of CNS metastasis and time interval between diagnosis of ovarian cancer and CNS involvement manifestation were the only factors significantly affecting survival.

CONCLUSIONS

Neurosurgical resection of brain metastasis from ovarian carcinoma is indicated in solitary lesions in the absence of systemic disease. The role of chemotherapy and stereotactic radiosurgery should be investigated.

Distant metastases in ovarian carcinoma

Distant metastases are unusual at presentation and during the course of ovarian carcinoma. The aim of the present study was to determine the incidence and prognostic factors of distant metastases consistent with stage IV disease in ovarian cancer patients. A retrospective chart review was conducted on 162 patients with epithelial ovarian carcinoma treated at our Unit between 1991 and 2000. Pertinent clinical information, pathologic data, treatment, and prognostic factors for survival following documentation of distant metastatic disease were collected. The significance of the association between metastatic status and various clinical variables was assessed using the standard chi-square test. Survival time was calculated from the time of diagnosis of ovarian cancer and from the time of diagnosis of the distant metastases. A logistic regression procedure was used to estimate the odds of metastatic status given the presence of certain clinical variables. A total of 67 metastatic sites were diagnosed in 50 patients. Thirteen patients (8%) had distant metastatic disease at the time of diagnosis, 37 patients (22%) had distant metastases at the time of recurrent of progressive disease. Site of metastases were: liver, 21; pleura, 11; lung, 8; central nervous system and skin, 7 each; extra-abdominal lymph nodes and spleen, 5 each; bone, 2; and breast, 1. Significant risk factors for the development of distant metastases were stage, grade, and lymph node involvement. Median interval time between diagnosis of ovarian cancer and documentation of metastatic disease was 44 months (range 3-105), and at the time of diagnosis of distant disease, 36 of 50 patients (72%) had other sites of disease (intra-abdominal or extra-abdominal). Median survival from diagnosis of distant disease was 12 months (range 1-58). In univariate analysis performance status (P = 0.03), the presence of other sites of disease (P = 0.04) and interval time between diagnosis of ovarian cancer and documentation of distant metases (P = 0.03) were the only factors significantly associated with survival. Long interval time remained significant for prognosis in multivariate analysis also (P = 0.04). Distant metastasis consistent with stage IV disease is a late complication that occurs in about one third of ovarian cancer patients. Prognosis after documentation of distant metastases is poor. We conclude the most important prognostic factor associated with survival is the interval time between diagnosis of ovarian cancer and documentation of distant metastases.

Brain as sanctuary site of relapse in germ cell cancer patients previously treated with chemotherapy

BACKGROUND

Post chemotherapy isolated relapse to the brain of germ cell cancer is potentially curable.

PATIENTS AND METHODS

We reviewed the experience of germ cell cancer with cerebral metastases at the CRC Wessex Medical Oncology Unit in Southampton. Patients were classified according to their presentation (initial diagnosis, solitary relapse or widespread). Treatment and outcome of these patients is presented and compared with previous series.

RESULTS

Of 1049 patients treated for metastatic germ cell cancer, 15 were diagnosed with cerebral metastases. Six patients had cerebral sanctuary site relapse, and underwent resection and cranial irradiation. Four of these are continuously disease free after treatment at 2, 67, 96, and 145 months from therapy, another is receiving chemotherapy for limited systemic relapse and the sixth has relapsed and died. Three further patients relapsed with cerebral disease in the presence of active disease elsewhere and each progressed and died. The final six patients had cerebral disease at presentation of whom five have progressed and died.

CONCLUSIONS

Isolated cerebral metastases occurring after successful systemic chemotherapy for germ cell cancer are curable. An aggressive salvage approach with surgery followed by radiotherapy is indicated.

Epithelial ovarian cancer metastasizing to the brain: a late manifestation of the disease with an increasing incidence

PURPOSE

We present the Royal Marsden Hospital experience of cerebral metastases from primary epithelial ovarian carcinoma (EOC) over the last 20 years and examine the evidence for an increasing incidence of EOC metastasizing to this site.

PATIENTS AND METHODS

A total of 3,690 women with EOC were seen at the Royal Marsden Hospital from 1980 to 2000. Eighteen of these patients developed cerebral metastases.

RESULTS

Median age at diagnosis of EOC was 52 years (range, 39 to 67). All patients received at least one line of platinum-based chemotherapy; 56% (10 of 18) received more than one line of treatment; 17% (three of 18), two lines; 11% (two of 18), three lines; and 28% (five of 18), four lines. The median treatment interval between each line of chemotherapy was 12, 18, and 4 months. The median interval between diagnosis and CNS relapse was 46 months (range, 12 to 113), in comparison with 5 and 7.5 months for hematogenous relapse in lung or liver, respectively (P <.001). The incidence of CNS metastases in our population from 1980 to 1984 was 0.2%; from 1985 to 1989, 0%; from 1990 to 1994, 0.3%; and from 1995 to 1999, 1.3% (P <.001). An analysis of data from the literature also suggests that the incidence of cerebral metastases from EOC has increased over time.

CONCLUSION

CNS metastases in EOC are a rare and late manifestation of the disease, occurring in patients with a prolonged survival caused by repeated chemosensitive relapses. An analysis of our data and the data from the literature suggests that the incidence of metastasis at this site in patients with EOC is increasing.

Intramedullary Spinal Cord Metastasis from Ovarian Carcinoma

BACKGROUND

Intramedullary spinal cord involvement by ovarian carcinoma is extremely rare.

CASE

A patient with stage IV serous cystadenocarcinoma of the ovary presented with neurologic complaints 16 months after primary treatment. Magnetic resonance imaging demonstrated a metastatic lesion in the intramedullary area of the spinal cord. No other site of metastatic disease was observed. The patient received three cycles of carboplatin with complete resolution of the neurologic symptoms and a remarkable reduction of the lesion. Following chemotherapy she was given radiotherapy on the spinal cord, but died 10 months later for disseminated abdominal disease, without neurologic symptoms.

CONCLUSION

Spinal cord involvement is unusual in ovarian carcinoma; multidisciplinary treatment, including chemotherapy and radiotherapy, may offer good palliation of the symptomatology.

Malignant Meningitis Secondary to Ovarian Carcinoma: An Unusual Occurrence

We report the case history of a patient with Stage IV ovarian carcinoma with leptomeningeal involvement. Although metastasis to other sites is relatively common, this scenario is rare.

Two BRCA1-positive epithelial ovarian tumors with metastases to the central nervous system: a case report

BACKGROUND

Cerebral metastasis secondary to ovarian cancer is a rare phenomenon. While no clear relationship to known prognostic factors is found, others suggest this as a biologically diverse behavior of ovarian cancer.

CASES

In a pilot study, 37 invasive epithelial ovarian cancer samples were analyzed to detect the frequency of BRCA1/BRCA2 mutations in the south of Sweden (results published). A retrospective follow-up revealed that 2 of these (2/37; 5.4%) patients developed central nervous system metastases during the course of their disease. Both patients had advanced surgical stage disease at the time of diagnosis, with histopathological serous type tumors that were negative for estrogen and progesterone receptors. One of these patients carried a germline BRCA1 mutation, whereas a somatic BRCA1 mutation was identified in the other patient.

CONCLUSIONS

To the best of our knowledge the molecular genetic profile of these tumors is not found in the literature and it is suggested that such analyses could provide some insight for a better understanding of this rare phenomenon.