Brain metastases from colorectal cancer: the role of surgical resection in selected patients

Immunotherapy: an emerging modality to checkmate brain metastasis

The diagnosis of brain metastasis (BrM) has historically been a dooming diagnosis that is nothing less than a death sentence, with few treatment options for palliation or prolonging life. Among the few treatment options available, brain radiotherapy (RT) and surgical resection have been the backbone of therapy. Within the past couple of years, immunotherapy (IT), alone and in combination with traditional treatments, has emerged as a reckoning force to combat the spread of BrM and shrink tumor burden. This review compiles recent reports describing the potential role of IT in the treatment of BrM in various cancers. It also examines the impact of the tumor microenvironment of BrM on regulating the spread of cancer and the role IT can play in mitigating that spread. Lastly, this review also focuses on the future of IT and new clinical trials pushing the boundaries of IT in BrM.

Where Are We Now and Where Might We Be Headed in Understanding and Managing Brain Metastases in Colorectal Cancer Patients?

OPINION STATEMENT

Compared to liver and lung metastases, brain metastases (BMs) from colorectal cancer (CRC) are rare and remain poorly investigated despite the anticipated rise in their incidence. CRC patients bearing BM have a dismal prognosis with a median survival of 3-6 months, significantly lower than that of patients with BM from other primary tumors, and of those with metastatic CRC manifesting extracranially. While liver and lung metastases from CRC have more codified treatment strategies, there is no consensus regarding the treatment of BM in CRC, and their management follows the approaches of BM from other solid tumors. Therapeutic strategies are driven by the number and localisation of the lesion, consisting in local treatments such as surgery, stereotactic radiosurgery, or whole-brain radiotherapy. Novel treatment modalities are slowly finding their way into this shy unconsented armatorium including immunotherapy, monoclonal antibodies, tyrosine kinase inhibitors, or a combination of those, among others.This article reviews the pioneering strategies aiming at understanding, diagnosing, and managing this disease, and discusses future directions, challenges, and potential innovations in each of these domains.

HIGHLIGHTS

• With the increasing survival in CRC, brain and other rare/late-onset metastases are rising. • Distal colon/rectal primary location, long-standing progressive lung metastases, and longer survival are risk factors for BM development in CRC. • Late diagnosis and lack of consensus treatment strategies make BM-CRC diagnosis very dismal. • Liquid biopsies using circulating tumor cells might offer excellent opportunities in the early diagnosis of BM-CRC and the search for therapeutic options. • Multi-modality treatment including surgical metastatic resection, postoperative SRS with/without WBRT, and chemotherapy is the best current treatment option. • Recent mid-sized clinical trials, case reports, and preclinical models show the potential of unconventional therapeutic approaches as monoclonal antibodies, targeted therapies, and immunotherapy. Graphical abstract.

Primary Tumor Resection Provides Survival Benefits for Patients with Synchronous Brain Metastases from Colorectal Cancer

Background: Brain metastases (BMs), particularly synchronous brain metastases, in colorectal cancer (CRC) patients are uncommon. The survival benefit of primary tumor resection (PTR) in patients with metastatic colorectal cancer is controversial. Whether PTR can bring survival benefits to patients with BMs of CRC has not been reported. Methods: From 2010 to 2016, 581 CRC patients with BMs from the Surveillance, Epidemiology, and End Results (SEER) database were divided into PTR and non-PTR groups. The log-rank test was used to compare the survival distributions. The Kaplan-Meier method was used to estimate survival. By controlling additional prognostic factors, a Cox proportional multivariate regression analysis was used to estimate the survival benefit of PTR. Results: The median overall survival for CRC patients with synchronous BMs was 3 months, with a 1-year survival rate of 27.2% and a 2-year survival rate of 12.8%. The PTR group contained 171 patients (29.4%), whereas the non-PTR group had 410 patients (70.6%). Patients who underwent PTR had a 1-year survival rate of 40.2% compared to 21.7% in those who did not (p < 0.0001). Cox proportional analysis showed that patients ≥60 years (hazard ratio [HR] 1.718, 95% confidence interval [CI] 1.423−2.075, p < 0.0001) had a shorter OS than patients < 60 years of age. OS was better in CEA-negative than in CEA-positive patients (HR 0.652, 95% CI 0.472−0.899, p = 0.009). Patients in whom the primary tumor was removed had considerably improved prognoses (HR 0.654, 95% CI 0.531−0.805, p < 0.0001). Subgroup analysis revealed that the PTR group achieved a survival advantage except for patients with CEA negative. Conclusions: Patients with synchronous BMs from CRC may benefit from primary tumor resection (PTR). Age, CEA level, and PTR were independent prognostic risk factors for CRC patients with synchronous BMs.

Survival Outcome of Surgical Resection vs. Radiotherapy in Brain Metastasis From Colorectal Cancer: A Meta-Analysis

Background

The incidence of brain metastasis from colorectal cancer (CRC) increases along with the greater survival rate for CRC because of the advances in therapeutic modalities. Local treatment strategies for brain metastasis include surgical resection and radiotherapy. Nevertheless, given the incongruent literature, the optimal therapeutic approach remains to be investigated. This study aims to systematically compare the real-world survival outcome of surgical resection and radiotherapy in patients with brain metastasis from CRC.

Methods

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines (PROSPERO, ID: CRD42021240200), the Cochrane Library, Embase, and Medline were searched from the inception of the database to August 2021. Meta-analyses were conducted with results pooled using hazard ratios with corresponding 95% CIs to evaluate the overall survival (OS) following local treatment for brain metastasis from CRC. Summary effects were evaluated using a series of random-effect models.

Results

In this review, 17 retrospective studies comprising 1,438 participants were included. In comparison with radiotherapy, the OS of patients who received brain metastasectomy was generally longer (HR, 0.53; 95% CI, 0.47–0.60). Extracerebral metastases (HR, 1.58; 95% CI, 1.34–1.86) and multiple brain metastases (HR, 1.38; 95% CI, 1.10–1.72) were associated with worse survival outcomes.

Conclusions

For patients with brain metastasis from CRC, the current real-world evidence demonstrated the survival benefit of aggressive neurosurgical management in suitable patients. Additionally, patients with extracerebral metastases and multiple brain metastases had worse survival outcomes.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=240200.

The impact of neurological performance and volumetrics on overall survival in brain metastasis in colorectal cancer: a retrospective single-center case series

Background

Brain metastasis (BM) of colorectal cancer is a disease with a poor prognosis of only a few months survival. However, it is difficult to estimate the individual prognosis of each patient due to the lack of definitive prognosis parameters. The number of metastases and the Karnofsky performance score are known predictors for survival. We investigated whether or not the neurological performance score and the tumor volumetrics are equally suitable predictors for survival.

Design

All patients with histologically diagnosed BM linked to colorectal cancer between 2012 and March 2020 were reviewed. The Medical Research Council Neurological Performance Score was used to quantify neurological performance. Univariate analysis with Kaplan-Meier estimate and log-rank test was performed. Survival prediction and multivariate analysis were performed employing Cox proportional hazard regression.

Results

Twenty-five patients were included in our analysis with an overall survival of 4.9 months after surgery of the BM. Survival decreased in the univariate analysis with increasing postoperative neurological performance score, low Karnofsky performance score, absence of radiation therapy and radiation therapy modality. The neurological performance score is a reliable scoring parameter for estimating the prognostic course analogous to the Karnofsky performance score. Neither preoperative nor post resection residual tumor volume had any impact on overall survival in our small cohort.

Conclusion

Our data suggest that the postoperative neurological performance is a valuable prognostic factor for colorectal cancer patients with BM. Tumor volumetrics show no correlation to survival. Further investigations with a larger number of cases are mandatory.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09435-1.

Risk Factors on the Incidence and Prognostic Effects of Colorectal Cancer With Brain Metastasis: A SEER-Based Study

Background

Colorectal cancer (CRC) with brain metastases (BM) is uncommon and often diagnosed at a late stage. The aims of this study were to identify the clinical factors that can influence the incidence of CRC patients with BM (CRCBM) and to investigate the impact of clinical factors and therapies on the outcomes of CRCBM.

Methods

Between 2010 and 2018, patients with CRCBM were enrolled under the Surveillance, Epidemiology, and End Results (SEER) program. Multivariable logistic and Cox regression models were used to identify risk factors and prognostic factors of BM. Kaplan–Meier curve and log-rank test were used to evaluate overall survival (OS) and tumor-specific survival (CSS) of CRCBM patients.

Results

A total of 195 (0.34%) CRC patients initially diagnosed with BM were included for analysis. The positive level of CEA, pN2a-b, and additional organ metastases were positively associated with developing BM from the CRC cohort (p < 0.05). The median OS and CSS of the BM patients were both 4.0 months, while the corresponding survival time in CRC patients without BM was 14.0 and 16.0 months, respectively (HR = 2.621, 95% CI = 2.061–3.333 for CSS; HR = 2.556, 95% CI = 2.026–3.225 for OS; log rank p < 0.001, each). Only systematic treatment was independently associated with better survival (p < 0.05, each).

Conclusions

Although the overall prognosis of CRCBM patients was extremely poor, the positive level of CEA, pN2a-b, and distant metastases could be bad risk factors for the incidence of CRCBM. In addition, only systematic treatment was found to be a negative prognostic factor for CRCBM patients. These related factors can provide more valuable reference for clinical individualized treatments.

Epidemiology and Outcomes of Patients With Brain Metastases From Colorectal Cancer-Who Are These Patients?

BACKGROUND

Brain metastases (BMs) from colorectal cancer (CRC) are unusual; however, an increase in incidence has been reported. The evidence available on the subject is scarce, and a better understanding is warranted. We aimed to characterize the epidemiology and the outcomes of patients with BMs from CRC.

PATIENTS AND METHODS

A cohort of patients with BMs from CRC was retrospectively evaluated. Patients were treated in a single center between May 2008 and April 2019. BMs were confirmed by brain computed tomography or magnetic resonance imaging.

RESULTS

A total of 247 consecutive patients were evaluated. Most patients had a left-sided primary tumor (193, 78%) and at least two extra-cranial metastatic sites (194, 78%). Ninety-six patients (39%) were RAS wild-type; 68 patients (27%) were RAS mutated; and 83 patients (34%) were not characterized. Median time from the initial diagnosis to BMs was 27.6 months (interquartile range, 13.1-46.9). Regarding local therapy, 43 patients (17.4%) were treated with BM surgery alone, 76 patients (30.8%) with radiotherapy (RT) alone, and 58 patients (23.5%) with both surgery and RT. Median overall survival (OS) was 2.9 months (95% confidence interval [CI], 2.2-3.5). Six-month and 1-year OS rates were 29% (95% CI, 23-25) and 13.5% (95% CI, 9.2-18.6), respectively. In a multivariable analysis, BM surgery alone (hazard ratio [HR], 0.56; P = .018), RT alone (HR, 0.51; P = .001), and surgery plus RT (HR, 0.27; P < .001) were associated with superior OS, whereas Eastern Cooperative Oncology Group Performance Status 3 or 4 (HR, 2.01; P = .009) and male gender (HR, 1.46; P = .012) were negative prognostic factors. RAS status was not associated with OS.

CONCLUSION

BMs occur late during the course of colorectal cancer and are more common in patients with a left-sided primary tumor and a high volume of metastatic disease. BMs from colorectal cancer are still associated with an extremely poor prognosis; however, selected patients may benefit from treatment with surgical resection and radiotherapy.

Patients with colorectal cancer and brain metastasis: The relevance of extracranial metastatic patterns predicting time intervals to first occurrence of intracranial metastasis and survival

The aim of the study was to investigate the predictive impact of extracranial metastatic patterns on course of disease and survival in patients with colorectal cancer (CRC) and brain metastasis (BM). A total of 228 patients (134 male [59%], 94 female [41%]) with histologically proven CRC and BM were classified into different groups according to extracranial metastatic patterns. Time intervals to metastatic events and survival times from initial CRC diagnosis, extracranial and intracranial metastasis were analyzed. Extracranial organs mostly affected were liver (102 of 228 [44.7%]) and lung (96 of 228 [42.1%]). Liver and lung metastases were detected in 31 patients (13.6%). Calculated over the entire course of disease, patients with lung metastasis showed longer overall survival (OS) than patients with liver metastasis or patients without lung metastasis (43.9 vs 34.6 [P = .002] vs 35.0 months [P = .002]). From the date of initial CRC diagnosis, lung metastasis occurred later in CRC history than liver metastasis (24.3 vs 7.5 months). Once lung metastasis was diagnosed, BM occurred faster than in patients with liver metastasis (15.8 vs 26.0 months; Δ 10.2 months). Accordingly, OS from the diagnosis of liver metastasis was longer than from lung metastasis (27.1 vs 19.6 months [P = .08]). Once BM was present, patients with lung metastasis lived longer than patients with liver metastasis (3.8 vs 1.1 months [P = .028]). Shortest survival times in all survival categories analyzed revealed patients with concurrent liver and lung metastasis. Patients with CRC and BM form a heterogeneous cohort where extracranial metastasis to liver or lungs predicts survival.

Brain metastases from primary colorectal cancer: is radiosurgery an effective treatment approach? Results of a multicenter study of the radiation and clinical oncology Italian association (AIRO)

OBJECTIVES

The prognosis of brain metastatic colorectal cancer patients (BMCRC) is poor. Several local treatments have been used, but the optimal treatment choice remains an unresolved issue. We evaluated the clinical outcomes of a large series of BMCRC patients treated in several Italian centers using stereotactic radiosurgery (SRS).

METHODS

185 BMCRC patients for a total of 262 lesions treated were evaluated. Treatments included surgery followed by post-operative SRS to the resection cavity, and SRS, either single-fraction, then hypofractionated SRS (HSRS). Outcomes was measured in terms of local control (LC), toxicities, brain distant failure (BDF), and overall survival (OS). Prognostic factors influencing survival were assed too.

RESULTS

The median follow-up time was 33 months (range 3-183 months). Surgery plus SRS have been performed in 28 (10.7%) cases, SRS in 141 (53.8%), and HSRS in 93 (35.5%). 77 (41.6%) patients received systemic therapy. The main total dose and fractionation used were 24 Gy in single fraction or 24 Gy in three daily fractions. Local recurrence occurred in 32 (17.3%) patients. Median, 6 months,1-year-LC were 86 months (95%CI 36-86), 87.2% ± 2.8, 77.8% ± 4.1. Median,6 months,1-year-BDF were 23 months (95%CI 9-44), 66.4% ± 3.9, 55.3% ± 4.5. Median,6 months,1-year-OS were 7 months (95% CI 6-9), 52.7% ± 3.6, 33% ± 3.5. No severe neurological toxicity occurred. Stage at diagnosis, Karnofsky Performance Status (KPS), presence and number of extracranial metastases, and disease-specific-graded-prognostic-assessment (DS-GPA) score were observed as conditioning survival.

CONCLUSION

SRS/HSRS have proven to be an effective local treatment for BMCRC. A careful evaluation of prognostic factors as well as a multidisciplinary evaluation is a valid aid to manage the optimal therapeutic strategy for CTC patients with BMs.

ADVANCES IN KNOWLEDGE

The prognosis of BMCRC is poor. Several local treatments was used, but optimal treatment choice remains undefined. Radiosurgery has proven to be an effective local treatment for BMCRC. A careful evaluation of prognostic factors and a multidisciplinary evaluation needed.

Survival benefit of lobectomy for glioblastoma: moving towards radical supramaximal resection

PURPOSE

Extent of resection remains a paramount prognostic factor for long-term outcomes for glioblastoma. As such, supramaximal resection or anatomic lobectomy have been offered for non-eloquent glioblastoma in an attempt to improve overall survival. Here, we conduct a propensity-matched analysis of patients with non-eloquent glioblastoma who underwent either lobectomy or gross total resection of lesion to investigate the efficacy of supramaximal resection of glioblastoma.

METHODS

Patients who underwent initial surgery for gross total resection or lobectomy for non-eloquent glioblastoma at our tertiary care referral center from 2010 to 2019 were included for this propensity-matched survival analysis. Propensity scores were generated with the following covariates: age, location, preoperative KPS, product of perpendicular maximal tumor diameters, and product of perpendicular FLAIR signal diameters. Inverse probability of treatment weighting (IPTW) with generated propensity scores was used to compare progression-free survival and overall survival.

RESULTS

Sixty-nine patients were identified who underwent initial resection of glioblastoma for non-eloquent glioblastoma from 2010 to 2019 (GTR = 37, lobectomy = 32). Using IPTW, overall survival (30.7 vs. 14.1 months) and progression-free survival (17.2 vs. 8.1 months were significantly higher in the lobectomy cohort compared to the GTR group (p < 0.001). There was no significant difference in pre-op or post-op KPS or complication rates between the two groups.

CONCLUSION

Our propensity-matched study suggests that lobectomy for non-eloquent glioblastoma confers an added survival benefit compared to GTR alone. For patients with non-eloquent glioblastoma, a supramaximal resection by means of an anatomic lobectomy should be considered as a primary surgical treatment in select patients if feasible.

Impact of Site-Specific Metastases on Surgical Value and Survival among Metastatic Colorectal Cancer Patients

We aimed to explore the potential prognostic impact of the metastatic site on the management approach and prognosis of stage IV colorectal cancer patients with synchronous metastases. Synchronous metastatic colorectal cancer patients reported to the Surveillance, Epidemiology, and End Results Program database between 2010 and 2013 were included in this study. Overall survival (OS) was compared between patients with different treatment options using risk-adjusted Cox proportional hazard regression models. Overall, 17,776 patients with stage IV colorectal cancer were identified. Of these patients, 2,052 (11.5%) underwent surgical resection for tumors at both the primary and meta-static sites. Patients who underwent surgical resection of both primary and metastatic sites with liver, lung, and simultaneous liver and lung metastases had a longer median OS ( P < 0.001) than patients who underwent nonsurgical treatments. Cox regression analysis revealed that surgical resection of both primary and metastatic sites was associated with a significantly enhanced OS ( P < 0.001). Colorectal cancer patients with hepatic or pulmonary metastases, who underwent metastasectomy, even in selected patients with both hepatic and pulmonary metastases after multidisciplinary evaluation, could have a better survival benefit than patients who underwent nonsurgical treatments.

Prognostic factors for survival in colorectal cancer patients with brain metastases undergoing whole brain radiotherapy: multicenter retrospective study

Whole brain radiotherapy (WBRT) is a mainstay of the treatment for brain metastases (BM). We evaluated prognostic factors in colorectal cancer (CRC) patients undergoing WBRT for BM. The medical records of 106 CRC patients undergoing WBRT for BM between 2000 and 2014 at three institutions were reviewed. Patient and tumor factors were analyzed to identify the prognostic factors for overall survival (OS) calculated from the date of BM diagnosis to the date of death or last follow-up. Surgical resection of BM was performed in six patients. The dose of WBRT was 30 Gy, and boost radiotherapy or stereotactic radiosurgery (8–23 Gy) was given to 15 patients. Systemic therapy for BM was administered in one patient before WBRT and 26 patients after WBRT. The median follow-up time was 3.9 months (range, 0.4–114.1 months). The median OS time was 3.9 months, and the 1-year OS rate was 18.2%. Older age (>65 years), multiple BM (≥3), elevated level of carcinoembryonic antigen (CEA, >5 ng/ml) at BM diagnosis, and extracranial metastases were adverse prognostic factors for OS. Patient with 0–1 factor showed better OS (at 1 year, 76.9%) than patients with 2 factors (16.7%) or 3–4 factors (4.2%; p < 0.001). In conclusion, we evaluated age, the number of BM, CEA level, and extracranial metastases as the prognostic factors for OS in CRC patients undergoing WBRT. Our result might be useful to develop prognostic models predicting survival for patients whom WBRT is intended for.

Prognostic scoring system for synchronous brain metastasis at diagnosis of colorectal cancer: A population-based study

BACKGROUND

Brain metastasis (BM) from colorectal cancer (CRC) is rarely encountered clinically, and its prognosis has not been fully evaluated.

AIM

To construct a scoring system and accurately predict the survival of patients with synchronous BM at diagnosis of CRC.

METHODS

A retrospective study of 371 patients with synchronous BM from CRC was performed, using the data from 2010 to 2014 from the Surveillance, Epidemiology, and End Results database. Survival time and prognostic factors were statistically analyzed by the Kaplan-Meier method and Cox proportional hazards models, respectively. A scoring system was developed using the independent prognostic factors, and was used to measure the survival difference among different patients.

RESULTS

For the 371 patients, the median overall survival was 5 mo, survival rates were 27% at 1 year and 11.2% at 2 years. Prognostic analysis showed that age, carcinoembryonic antigen level and extracranial metastasis to the liver, lung or bone were independent prognostic factors. A scoring system based on these three prognostic factors classified the patients into three prognostic subgroups (scores of 0-1, 2-3, and 4). The median survival of patients with scores of 0-1, 2-3 and 4 was 14, 5 and 2 mo, respectively (P < 0.001). Subgroup analysis showed that there were significant differences in prognosis among the groups. Score 2-3 vs 0-1: hazard ratio (HR) = 2.050, 95%CI: 1.363-3.083; P = 0.001; score 4 vs 0-1: HR = 3.721, 95%CI: 2.225-6.225; P < 0.001; score 2-3 vs 4: HR = 0.551, 95%CI: 0.374-0.812; P = 0.003.

CONCLUSION

The scoring system effectively distinguishes long-term and short-term survivors with synchronous BM from CRC. These results are helpful in providing a reference for guiding therapy.

Brain metastasis from colorectal cancer: clinical characteristics, timing, survival and prognostic factors

Background: Brain metastasis (BM) from colorectal cancer (CRC) seriously affects the survival and quality of life of patients. However, this disease is not fully understood. It is not clear when follow-up monitoring should be conducted to achieve early diagnosis. Furthermore, the reported prognostic factors have varied among different studies. Our study aims to determine the clinicopathological, survival and prognostic factors, as well as the timing of BM occurrence.Methods: We retrospectively studied the patients with BM from CRC between January 2000 and July 2017. The clinicopathologic features were assessed, and the time from primary tumor surgery and extracranial metastases (lung, liver and bone) to the occurrence of BM was calculated, respectively. Survival time after BM was statistically analyzed. Multivariate Cox analysis was carried out to determine the independent factors that affected survival.Results: 52 patients were analyzed. Most of the patients (86.5%) had combined extracranial metastases when BM was diagnosed, and lung was the commonest extracranial metastasis location. The median time interval from CRC surgery to the diagnosis of BM was 20.5 months, and the median time interval from lung, liver and bone metastases to BM was 7, 5 and 2 months, respectively. After diagnosis of BM, the median survival was 9 months. Extracranial metastases (p =.012) and Karnofsky performance status (p =.025) were independent prognostic factors based on multivariate analysis.Conclusion: BM from colorectal cancer often occur in the late stage, and has an extremely poor prognosis. Identifying the timing of brain metastasis can help to detect this disease early.

Treatment modalities and relative survival in patients with brain metastasis from colorectal cancer

Standard treatment options for brain metastases (BM) from colorectal cancer (CRC) are controversial. The purpose of this study was to evaluate the efficacy of multidisciplinary treatment modalities and provide optimal therapeutic strategies for selected patients with different clinical characteristics. All eligible patients diagnosed with BM from CRC during the past two decades (1997-2016) were identified in our center. Clinical characteristics, treatment modalities and relative survival were retrospectively analyzed. Median overall survival after the identification of BM was 6 months. The 1- and 2- year survival rates were 29.40% and 5.70%, respectively. On multivariate analysis, the number of BMs, Karnofsky performance score and the treatment modalities were found to be independent prognostic factors (the p-value was 0.006, 0.001 and < 0.001, respectively). In conclusion, multidisciplinary treatment is supported to be the optimal treatment for patients with BM from CRC. For patients with single brain metastases and KPS > 70, neurosurgery combined with chemotherapy could provide an additional survival benefit. For patients with multiple brain metastases or KPS ≤ 70, radiotherapy plus chemotherapy may be appropriate.

Bone metastasis predicts poor prognosis of patients with brain metastases from colorectal carcinoma post aggressive treatment

Purpose

The presence of brain metastasis (BM) in patients with colorectal cancer (CRC) is usually associated with terminal-stage illness; however, a subgroup of patients receiving aggressive treatment can have a satisfactory prognosis. This study was designed to investigate the profile of prognostic factors in CRC patients with BM treated aggressively.

Patients and methods

CRC patients with BM were retrospectively reviewed. Survival analysis was performed to identify potential prognostic factors in the entire cohort of patients and a subgroup of patients treated aggressively. Aggressive treatments included surgical resection, radiotherapy, and/or chemotherapy. Overall survival was defined as the time between the diagnosis of BM and death or until the date of the last follow-up visit.

Results

A total of 78 CRC patients were confirmed as having BM. Sixty-eight of them had extracranial metastases at the time of their BM diagnosis. The most common sites of extracranial metastases were lung (n=51, 65.4%), followed by liver (n=25, 32.1%) and bone (n=12, 15.4%). Fifty-one patients who were treated aggressively had significantly longer overall survival than those who accepted palliative care (14.1 months vs 2.0 months, P<0.0001). Multivariate analysis was applied, and the results showed that aggressive treatment (n=51), recursive partitioning analysis class I/II (hazard ratio [HR]=0.27, 95% CI: 0.12–0.6, P=0.001), and fewer BM (HR=0.4, 95% CI: 0.21–0.78, P=0.07) predicted longer survival. In contrast, the presence of bone metastasis, rather than lung or liver metastasis, at the time of diagnosis of BM (HR=2.38, 95% CI: 1.08–5.28, P=0.032) predicted a poor prognosis.

Conclusions

Although the prognosis of CRC patients having BM is frequently very poor, those with good performance status and few brain lesions responded to aggressive treatment, while those with bone metastasis at the time of diagnosis of BM had relatively dismal survival rates, even when treated aggressively.

A Retroviral Replicating Vector Encoding Cytosine Deaminase and 5-FC Induces Immune Memory in Metastatic Colorectal Cancer Models

Treatment of tumors with Toca 511, a gamma retroviral replicating vector encoding cytosine deaminase, followed by 5-fluorocytosine (5-FC) kills tumors by local production of 5-fluorouracil (5-FU). In brain tumor models, this treatment induces systemic anti-tumor immune responses and long-term immune-mediated survival. Phase 1 Toca 511 and Toca FC (extended-release 5-FC) clinical trials in patients with recurrent high-grade glioma show durable complete responses and promising survival data compared to historic controls. The work described herein served to expand on our earlier findings in two models of metastatic colorectal carcinoma (mCRC). Intravenous (i.v.) delivery of Toca 511 resulted in substantial tumor-selective uptake of vector into metastatic lesions. Subsequent treatment with 5-FC resulted in tumor shrinkage, improved survival, and immune memory against future rechallenge with the same CT26 CRC cell line. Similar results were seen in a brain metastasis model of mCRC. Of note, 5-FC treatment resulted in a significant decrease in myeloid-derived suppressor cells (MDSCs) in mCRC tumors in both the liver and brain. These results support the development of Toca 511 and Toca FC as a novel immunotherapeutic approach for patients with mCRC. A phase 1 study of i.v. Toca 511 and Toca FC in solid tumors, including mCRC, is currently underway (NCT02576665).

Brain metastasis from colorectal cancer: a single center experience

Purpose

The detection rate of brain metastasis (BM) from colorectal cancer (CRC) is increasing. This study was designed to analyze the clinical features of BM and prognosis according to the therapeutic modalities.

Methods

A total of 19 cases were collected in this study between November 2008 and December 2015. We reviewed the patients' demographic data and the clinical features of BM retrospectively and investigated their prognostic significance.

Results

Nineteen patients included 8 male and 11 female patients. The median age at diagnosis of BM was 62.4 years (range, 32–83 years). The median interval between diagnosis of CRC and BM was 39 months (range, 0–98 months). Eighteen patients (94.7%) had extracranial metastasis at the diagnosis of BM. Lung was the most common site of extracranial metastasis in 14 patients (73.7%). Synchronous BMs were found at the diagnosis of primary CRC in 2 patients (10.5%). The location of primary CRC was the colon in 6 patients (31.6%) and the rectum in 13 patients (68.4%). At the diagnosis of BM, 10 patients (52.6%) had a solitary BM. The common neurologic symptoms were headache in 8 cases (42.1%) and ataxia in 6 cases (31.6%). The median survival after the diagnosis of BM was 3 months (range, 1–10 months). The patients who underwent surgery plus stereotactic radiosurgery (SRS) had an improved survival (range, 3–10 months) than the other patients (range, 1–6 months) (P = 0.016).

Conclusion

In patients with BM from CRC, surgical resection plus SRS might improve survival.

A systematic review to assess the management of patients with cerebral metastases secondary to colorectal cancer

BACKGROUND

Colorectal cancer (CRC) rarely metastasizes to the brain. The incidence of cerebral metastases (CM) is estimated between 1 and 3%. Given the improved survival from advanced CRC as a result of surgical and oncological advances, it is anticipated that the incidence of patients with CM from CRC will rise over the next few years. The aim of this article was to systematically review the treatment options and outcome of patients with CM from CRC.

METHODS

PubMed and Medline databases were examined using the search words or MESH headings "colorectal" "cancer/carcinoma/adenocarcinoma", "cerebral"/"brain" and "metastases/metastasis".

RESULTS

CM from CRC are diagnosed on average 28.3 months after the primary tumour. The median survival time following diagnosis is 5.3 months. Surgery (with or without associated radiotherapy), stereotactic radiosurgery, whole brain radiotherapy and best supportive care result in median survival of 10.3, 6.4, 4.4 and 1.8 months, respectively. On average, the 1-year overall survival rate for patients with CM from CRC regardless of the treatment modality is estimated to be around 24%.

CONCLUSIONS

The prognosis of patients with CM from CRC is dismal. Surgery may increase survival, but the additional benefit of perioperative radiotherapy cannot be ascertained due to paucity of data. Further studies are required to identify the role of the different oncological and surgical therapies and identify those patients likely to benefit most. Identification of patients who are at higher risk of developing brain metastases may be another important area for future research.

Brain metastases from colorectal cancer: characteristics and management

BACKGROUND

Brain metastases (BMs) are the most common intracranial neoplasms in adults, but they rarely arise from colorectal cancer (CRC). The objective of this study was to report an overview of the characteristics and current management of CRC BMs.

METHODS

A systematic review on CRC BMs was performed using Medline database from 1983 to 2015. The search was limited to studies published in English. Review articles, not relevant case report or studies or studies relating to animal and in vitro experiments were excluded.

RESULTS

BMs occurred in 0.06-4% of patients with CRC. Most BMs were metachronous and were associated with lung (27-92%) and liver (12-80%) metastases. Treatment options depended on the number of BMs, the general conditions of the patient and the presence of other metastases. Most frequent treatment was whole-brain radiotherapy (WBRT) alone (36%), with median overall survival comprised between 2 and 9 months. Median overall survival was better after surgery alone (from 3 to 16.2 months), or combined with WBRT (from 7.6 to 14 months). After stereotactic radiosurgery alone, overall survival could reach 9.5 months. Many favourable prognostic factors were identified, such as high Karnofsky performance status, low recursive partitioning analysis classes, lack of extracranial disease, low number of BMs and possibility to perform surgical treatment.

CONCLUSION

BMs from CRC are rare. In the presence of favourable prognostic factors, an aggressive management including surgical resection with or without WBRT or stereotactic radiosurgery can improve the overall survival.

Clinical characteristics and treatment outcomes of patients with colorectal cancer who develop brain metastasis: a single institution experience

BACKGROUND

The development of brain metastasis (BM) in patients with colorectal cancer (CRC) is a rare and late event. We sought to investigate the clinical characteristics, disease course and safety using biologic agents in our patients with CRC who develop brain metastases.

METHODS

A retrospective review of patients with CRC with brain metastases treated at our institution from 01/2005-01/2015 was performed. Survival analysis was performed using the Kaplan-Meier method.

RESULTS

Forty patients were included in the analysis. Median age was 55.5 years, 67.5% were males, and 28% had a KRAS mutation. Twenty-four percent were treatment-naive at the time of BM diagnosis. Patients had a median of two brain lesions. Sixty-five percent of the patients were treated with radiotherapy alone, 22.5% had both surgical resection and brain radiotherapy. Median overall survival was 3.2 months after development of BM. Overall survival was longer in patients who received combined modality local therapy compared to patients treated with surgical resection or radiotherapy alone. Patients who received systemic treatment incorporating biologics following development of BM had a median overall survival of 18.6 months. Overall, the administration of biologic agents was safe and well tolerated.

CONCLUSIONS

In summary, BM is an uncommon and late event in the natural history of metastatic CRC. The ability to deliver combined-modality local brain therapy as well as availability of more systemic therapy options appear to lead to improved outcomes.

Central nervous system metastasis secondary to colorectal cancer: a retrospective cohort study of 20 cases

Introduction

Involvement of the central nervous system (CNS) secondary to colorectal cancer is infrequent and associated with a poor prognosis. Its treatment is extrapolated from metastases of other origins as the information available on this scenario is limited. The goal of this study is to assess the clinical characteristics of a series of patients and determine the results in terms of progression-free survival (PFS) and global survival.

Method

The records of patients with CNS metastasis of colorectal origin who were treated in this facility between the years 2001 and 2016 were reviewed retrospectively.

Results

20 patients with CNS lesions of this origin were identified. Of these, 45% were male and 55% were female (average age 65.5 years). The histology corresponded to tubular adenocarcinoma in 95% of cases. Around 85% of the patients showed a neurological deficit, and their recursive partitioning analysis (RPA) classifications were 1 in 20%, 2 in 55%, and 3 in 25% of the cases studied. The treatments provided were: holocerebral radiotherapy (45%), stereotactic radiosurgery (25%), surgery followed by holocerebral radiotherapy (25%), and exclusively palliative care (5%). The PFS was 2.6 months from treatment of the CNS lesion, while the median survival was 3.8 months. The survival times for patients receiving different treatments were as follows: surgery plus holocerebral radiotherapy 16.2 months, stereotactic radiotherapy 12 months, and holocerebral radiotherapy 2.4 months (p = 0.003).

Conclusion

The prognosis for patients with metastasis of colorectal origin is poor. The patients treated with surgery or stereotactic radiotherapy can have a greater survival.

Brain metastasis in advanced colorectal cancer: results from the South Australian metastatic colorectal cancer (SAmCRC) registry

Objective:

Brain metastasis is considered rare in metastatic colorectal cancer (mCRC); thus, surveillance imaging does not routinely include the brain. The reported incidence of brain metastases ranges from 0.6% to 3.2%.

Methods:

The South Australian mCRC Registry (SAmCRC) was analyzed to assess the number of patients presenting with brain metastasis during their lifetime. Due to small numbers, a descriptive analysis is presented.

Results:

Only 59 patients of 4,100 on the registry at the time of analysis had developed brain metastasis (1.4%). The clinical characteristics of those with brain metastasis were as follows: the median age was 65.3 years and 51% were female. Where the V-Ki-ras2 Kirsten rat sarcoma viral oncogene homolog (KRAS) mutation status of the tumor was known, the majority harbored a KRAS mutation (55%); 31 (53%) underwent craniotomy and 55 (93%) underwent whole-brain radiotherapy. The median survival time from diagnosis of brain metastasis was 4.2 months (95% confidence interval 2.9–5.5). Patients who underwent craniotomy and radiotherapy had superior survival compared to those who underwent whole-brain radiotherapy (8.5 months vs. 2.2 months, respectively). Data from the SAmCRC (a population-based registry) confirm that brain metastases are rare and the median time to development is approximately 2 years.

Conclusions:

Brain metastasis is a rare outcome in advanced CRC. Patients within the registry tended to be female, young in age, and harbored with higher rates of KRAS mutations. Whether routine surveillance brain scanning should be considered remains controversial given the relative rarity of developing brain metastases in mCRC and ultimately, most patients with central nervous system involvement die from their extracranial disease.

Ten-Year Survival of a Patient Treated with Stereotactic Gamma Knife Radiosurgery for Brain Metastases from Colon Cancer with Ovarian and Lymph Node Metastases: A Case Report

Brain metastasis from colorectal cancer is infrequent and carries a poor prognosis. Herein, we present a patient alive 10 years after the identification of a first brain metastasis from sigmoid colon cancer. A 39-year-old woman underwent sigmoidectomy for sigmoid colon cancer during an emergency operation for pelvic peritonitis. The pathological finding was moderately differentiated adenocarcinoma. Eleven months after the sigmoidectomy, a metastatic lesion was identified in the left ovary. Despite local radiotherapy followed by chemotherapy, the left ovarian lesion grew, so resection of the uterus and bilateral ovaries was performed. Adjuvant chemotherapy with tegafur-uracil (UFT)/calcium folinate (leucovorin, LV) was initiated. Seven months after resection of the ovarian lesion, brain metastases appeared in the bilateral frontal lobes and were treated with stereotactic Gamma Knife radiosurgery. Cervical and mediastinal lymph node metastases were also diagnosed, and irradiation of these lesions was performed. After radiotherapy, 10 courses of oxaliplatin and infused fluorouracil plus leucovorin (FOLFOX) were administered. During FOLFOX administration, recurrent left frontal lobe brain metastasis was diagnosed and treated with stereotactic Gamma Knife radiosurgery. In this case, the brain metastases were well treated with stereotactic Gamma Knife radiosurgery, and the systemic disease arising from sigmoid colon cancer has been kept under control with chemotherapies, surgical resection, and radiotherapy.

Systematic review: brain metastases from colorectal cancer--Incidence and patient characteristics

Background

Brain metastases (BM) from colorectal cancer (CRC) are a rare event. However, the implications for affected patients are severe, and the incidence has been reported to be increasing. For clinicians, knowledge about the characteristics associated with BM is important and could lead to earlier diagnosis and improved survival.

Method

In this paper, we describe the incidence as well as characteristics associated with BM based on a systematic review of the current literature, following the PRISMA guidelines.

Results

We show that the incidence of BM in CRC patients ranges from 0.6 to 3.2 %. BM are a late stage phenomenon, and young age, rectal primary and lung metastases are associated with increased risk of developing BM. Molecular markers such as KRAS, BRAF, NRAS mutation as well as an increase in CEA and CA19.9 levels are suggested predictors of brain involvement. However, only KRAS mutations are reasonably well investigated and associated with an increased risk of BM.

Conclusion

The incidence of BM from CRC is 0.6 to 3.2 % and did not seem to increase over time. Development of BM is associated with young age, lung metastases, rectal primary and KRAS mutation. Increased awareness of brain involvement in patients with these characteristics is necessary.

Prognostic factors and multidisciplinary treatment modalities for brain metastases from colorectal cancer: analysis of 93 patients

Background

The purpose of this study was to review patient characteristics and evaluate the potential factors affecting prognosis in cases of brain metastasis (BM) from colorectal cancer (CRC).

Methods

We retrospectively reviewed 93 cases of BM from CRC in our hospital. Patient demographics, neurologic symptoms, and location and number of BMs were recorded. Factors analyzed included: age; sex; Karnofsky performance score; number of BMs; presence of extracranial metastases; dimensions; location of tumors; treatment modalities.

Results

The overall 1- and 2-year survival rates were 27.7 and 9.9 %. On multivariate analysis, the number of BMs, extracranial metastases and the initial treatment modalities were found to be independent prognostic factors for overall survival. Patients treated with surgical resection followed by WBRT or SRS had an improved prognosis relative to those treated with surgery alone (P = 0.02 and P = 0.02, respectively). No significance difference in survival rate was found between patients treated with SRS alone or SRS plus WBRT (P = 0.11).

Conclusions

Surgical resection of BMs from CRC in selected patients may help prolong survival. Additional radiotherapy following surgery is valuable in improving prognosis. Extracranial metastasis, multiple BM lesions and initial non operation can be considered as independent factors associated with poor prognosis.

Colorectal cancer: Metastases to a single organ

Colorectal cancer (CRC) is a common malignancy worldwide. In CRC patients, metastases are the main cause of cancer-related mortality. In a group of metastatic CRC patients, the metastases are limited to a single site (solitary organ); the liver and lungs are the most commonly involved sites. When metastatic disease is limited to the liver and/or lungs, the resectability of the metastatic lesions will dictate the management approach and the outcome. Less commonly, the site of solitary organ CRC metastasis is the peritoneum. In these patients, cytoreduction followed by hyperthermic intraperitoneal chemotherapy may improve the outcome. Rarely, CRC involves other organs, such as the brain, bone, adrenals and spleen, as the only site of metastatic disease. There are limited data to guide clinical practice in these cases. Here, we have reviewed the disease characteristics, management approaches and prognosis based on the metastatic disease site in patients with CRC with metastases to a single organ.

Brain Metastasis in Colorectal Cancer Patients: Survival and Analysis of Prognostic Factors

BACKGROUND

The purpose of the study was to characterize the rare cohort of patients (pts) with metastatic colorectal cancer (mCRC) and brain metastasis (BM) and to identify prognostic subgroups.

PATIENTS AND METHODS

In collaboration with the Munich Cancer Registry, pts with mCRC and BM who were diagnosed between 1998 and 2011 were identified. Survival from the time of first diagnosis of colorectal cancer (CRC) (OS-1), from the time of diagnosis of metastatic disease (OS-2) and of BM (OS-3) was calculated regarding (1) the temporal occurrence of extra- and intracranial metastasis (meta- vs. synchronous) and (2) tumor and patient characteristics. For survival analysis the Kaplan-Meier estimator and Cox regression models were used.

RESULTS

A total of 228 pts (134 male [59%], 94 female [41%]) were identified. The median age was 63 years (142 pts [62%] were 65 years of age or younger). Most pts presented with primary tumors staged T3/4, N+, Grade 2. The primary tumor was located predominantly in the left colon (155 pts; 68%), especially in the rectum (95 pts; 42%). Median OS-1 was 35.6 months (95% confidence interval [CI], 30.1-41.1 months), OS-2 was 16.5 months (95% CI, 13.9-19.1 months), and OS-3 was 2.0 months (95% CI, 1.5-2.5 months). Median time from first CRC diagnosis to BM was 29.2 months. Subsequent BM after extracranial metastasis were observed in 184 pts (80.7%), whereas 31 pts (13.6%) presented with solitary BM. Univariate analysis did not reveal a prognostic variable for overall survival after diagnosis of BM.

CONCLUSION

This study presents the largest number of pts with mCRC and BM analyzed to date. The results show that most mCRC pts develop BM as a late step in the course of disease. Median time from first CRC diagnosis to BM is 29.2 months. Only a few pts were diagnosed with BM early in the disease or with solitary BM. When BM is present survival is poor.

Tumor marker analyses in patients with brain metastases: patterns of practice and implications for survival prediction research

This study aims to explore patterns of practice of tumor marker analyses and potential prognostic impact of abnormal markers in patients with brain metastases from solid tumors. Previously, lactate dehydrogenase (LDH) and albumin were identified as relevant biomarkers. We performed a retrospective analysis of 120 patients with known LDH and albumin treated with whole-brain radiotherapy (WBRT) in two different situations: (1) brain metastases detected at initial cancer diagnosis (n = 46) and (2) brain metastases at later time points (n = 74, median interval 13 months). Twenty-six patients (57 %) from group 1 had at least one tumor marker analyzed, and 11 patients (24 %) had abnormal results. Twenty-two patients (30 %) from group 2 had at least one tumor marker analyzed, and 16 patients (22 %) had abnormal results. When assuming that LDH and albumin would be standard tests before WBRT, additional potential biomarkers were found in 36 % of patients with normal LDH and albumin. Marker positivity rates were for example 80 % for carcinoembryonic antigen (CEA) in colorectal cancer and 79 % for CA 15-3 in breast cancer. Abnormal markers were associated with presence of liver metastases. CA 15-3 values above median predicted shorter survival in patients with breast cancer (median 1.9 vs. 13.8 months, p = 0.1). Comparable trends were not observed for various markers in other tumor types. In conclusion, only a minority of patients had undergone tumor marker analyses. Final group sizes were too small to perform multivariate analyses or draw definitive conclusions. We hypothesize that CA 15-3 could be a promising biomarker that should be studied further.

Brain metastasis from colorectal carcinoma: a single cancer centre experience

PURPOSE

Brain metastases (BM) from colorectal cancer (CRC) are rare. As survival increases in patients with metastatic CRC, it is hypothesised that new metastatic patterns will emerge: for instance, as CRC with limited metastatic involvement of the liver and lung can now be successfully resected, we propose that sites, previously rarely involved in metastatic spread, will become more common. The objective of this study was to describe the experience with BM from CRC in a single cancer centre.

METHODS

A prospectively compiled database (1988-2012) of patients with CRC treated in a tertiary referral hospital was retrospectively examined. Patients with a histological diagnosis of CRC and radiologically documented BM were included. Clinical information (including patient demographics, primary and metastatic disease factors) was obtained from medical records.

RESULTS

Eleven patients (0.3 % of 4219 patients) were identified (8 male, 3 female). The median age at CRC diagnosis was 70 years (range 55-80 years) while the median age at diagnosis of BM was 73 years (range 56-83 years). Three patients diagnosed with synchronous metastases underwent palliative treatment while eight patients had undergone surgical resection of the primary tumour with curative intent a median of 24 months (range 0-48 months) prior to diagnosis of BM. 10/11 patients were symptomatic at diagnosis of BM. All were diagnosed using computed tomography and managed palliatively. The cerebellum was most the frequently involved site. The median overall survival time following diagnosis of BM was 2.5 months (range 2-9 months). Notably, 8/11 patients were diagnosed in the latter 8 years of the study period (between 2004 and 2012).

CONCLUSION

With increased survival, improved systemic therapy and aggressive approaches to surgical management of "classical" metastases from CRC, it is likely that a changing pattern of metastases will emerge. As survival rates increase, we propose that metastatic sites, which were previously considered rare (e.g. brain), will now become more common and thus, surgeons must recognise pertinent symptomatology.

Brain metastases in gastrointestinal cancers: is there a role for surgery?

About 10% of all cancer patients will develop brain metastases during advanced disease progression. Interestingly, the vast majority of brain metastases occur in only three types of cancer: Melanoma, lung and breast cancer. In this review, we focus on summarizing the prognosis and impact of surgical resection of brain metastases originating from gastrointestinal cancers such as esophageal, gastric, pancreatic and colorectal cancer. The incidence of brain metastases is <1% in pancreatic and gastric cancer and <4% in esophageal and colorectal cancer. Overall, prognosis of these patients is very poor with a median survival in the range of only months. Interestingly, a substantial number of patients who had received surgical resection of brain metastases showed prolonged survival. However, it should be taken into account that all these studies were not randomized and it is likely that patients selected for surgical treatment presented with other important prognostic factors such as solitary brain metastases and exclusion of extra-cranial disease. Nevertheless, other reports have demonstrated long-term survival of patients upon resection of brain metastases originating from gastrointestinal cancers. Thus, it appears to be justified to consider aggressive surgical approaches for these patients.

Brain metastasis from gastrointestinal cancers: a systematic review

BACKGROUND

Brain metastases (BM) from the gastrointestinal tract (GIT) cancers are relatively rare. Despite those advances in diagnostic and treatment options, life expectancy and quality of life in these patients are still poor. In this review, we present an overview of the studies which have been previously performed as well as a comprehensive strategy for the assessment and treatment of BM from the GIT cancers.

METHOD

To obtain information on brain metastases from GIT, we performed a systematic review of Medline, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL). The collected data included patient characteristics, primary tumor data and brain metastases data.

RESULT

In our search of the literature, we found 74 studies between 1980 and 2011, which included 2538 patients with brain metastases originated from gastrointestinal cancer. Analysis of available data showed that among 2538 patients who had brain metastases from GIT, a total of 116 patients (4.57%) had esophageal cancer, 148 patients (5.83%) had gastric cancer, 233 patients (9.18%) had liver cancer, 13 patients had pancreas cancer (0.52%) and 2028 patients (79.90%) had colorectal cancer. The total median age of the patients was 58.9 years.

CONCLUSION

Brain metastases have been considered the most common structural neurological complication of systemic cancer. Due to poor prognosis they influence the survival rate as well as the quality of life of the patients. The treatment of cerebral metastasis depends on the patients' situation and the decisions of the treating physicians. The early awareness of a probable metastasis from GI to the brain will have a great influence on treatment outcomes as well as the survival rate and the quality-of-life of the patients.

Prognostic factors and treatment effects in patients with curatively resected brain metastasis from colorectal cancer

BACKGROUND

Colorectal cancer infrequently causes brain metastasis, and the prognosis is poor.

OBJECTIVE

The aim of this study was to identify the prognostic factors associated with survival and outcome of treatment for patients with brain metastasis from colorectal cancer.

DESIGN

This is a retrospective study from a prospectively collected database.

SETTINGS

The investigation took place in a high-volume multidisciplinary tertiary cancer center in Japan.

PATIENTS

From 1979 to 2010, 113 consecutive patients who were treated for brain metastasis from colorectal cancer were identified.

MAIN OUTCOME MEASURES

The primary outcome measure was overall survival.

RESULTS

Sixty-three patients had neurosurgical resection (including curative resection for 46 patients) followed by whole brain radiotherapy, 9 had stereotactic radiosurgery, 30 had whole brain radiotherapy, and 11 had steroid and palliative care. As a whole, the overall median survival time from diagnosis of brain metastasis was 5.4 months (95% CI, 4.3-7.6 months), and the 1-year survival rate was 29% (95% CI, 22%-38%). In the group of patients who underwent curative neurosurgical resection, the overall median survival time was 15.2 months (95% CI, 9.2-17.8 months), and the 1-year survival rate was 57% (95% CI, 43%-71%). On multivariate analysis, 1 or 2 brain metastatic lesions, no extracranial metastatic lesions, and neurosurgical resection were independent favorable prognostic factors overall (p = 0.0057, 0.0197, and <0.0001), and 1 or 2 brain metastatic lesions, no extracranial metastatic lesion, and no emergence of secondary brain metastatic lesions were independent favorable prognostic factors in the group of patients who underwent curative neurosurgical resection (p = 0.0137, 0.0081, and 0.0010).

LIMITATIONS

This study was limited by its single-institute, retrospective, nonrandomized design and selection bias.

CONCLUSIONS

Neurosurgical resection in select patients is a reasonable option for brain metastasis from colorectal cancer, although it is not associated with long-term (5-year) survival. (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A121 ).

Clinical outcome with gamma-knife surgery or surgery for brain metastases from colorectal cancer

The aim of this study was to investigate the clinical outcomes after gamma knife surgery (GKS) or surgery as the first treatment for brain metastases in colorectal cancer (CRC). Of the 4350 patients diagnosed with CRC at our institution identified from 1987 to 2009, 27 patients who underwent GKS (GKS group) and 11 who underwent surgery (surgery group) were included. The oncologic outcomes were compared between the two groups. Local control was significantly better in the surgery group than in the GKS group (90% versus [vs.] 71.4%, respectively; p=0.006). The rate of symptom relief after 3 months was significantly higher in the surgery group than in the GKS group (72.7 vs.18.5%, respectively; p=0.005). The median survival after GKS was 5.6 months and surgery was 16.2 months. In multivariate analysis, controlled primary tumor (p=0.038) and solitary metastasis (p=0.028) were correlated with prolonged overall survival, whereas surgery (p=0.034) was associated with longer local control. Surgery for brain metastasis from CRC is more advantageous in local control and neurologic symptom palliation than GSK. In multivariate analysis, overall survival was associated with controlled primary tumor and solitary metastasis.