Complete remission of brain metastases from ovarian carcinoma with carboplatin

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.

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.

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.

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.

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.

Coexistent intramedullary spinal cord and choroidal metastases in ovarian cancer

Involvement of intramedullary spinal cord and the choroid by ovarian cancer is rare, and coexistence of metastases at these sites is extremely rare and has never been reported. This condition rapidly progresses to a neurological emergency; however, an efficient standard treatment method is not available for this rare condition. The case presented herein is of a female patient with stage II, poorly differentiated serous cystadenocarcinoma of the ovary. She presented with blindness and other neurologic complaints during the course of treatment for a recurrence at 50 months after the primary surgical treatment for the tumor. Magnetic resonance imaging (MRI) revealed intramedullary spinal cord metastasis and choroidal metastasis, coexisting with multiple brain metastases and intra-abdominal lesions. Neurological emergency was prevented by administering whole-brain irradiation therapy followed by systemic chemotherapy. Early diagnosis and multidisciplinary treatment, including radiotherapy and chemotherapy, may offer good palliation for such unusual metastases of ovarian cancer.

Plasma and cerebrospinal fluid pharmacokinetics of topotecan in a phase I trial of topotecan, tamoxifen, and carboplatin, in the treatment of recurrent or refractory brain or spinal cord tumors

PURPOSE

This study was designed to ascertain the dose-limiting toxicities (DLT) and maximally tolerated doses of the combination of fixed-dose tamoxifen and carboplatin, with escalating doses of topotecan, and to determine the pharmacokinetics of topotecan in the plasma and cerebrospinal fluid.

METHODS

Tamoxifen 100 mg po bid, topotecan 0.25, 0.5, 0.75, or 1.0 mg/m(2)/d IV, administered as a 72 h continuous infusion on days 1-3, followed by carboplatin AUC = 3, IV on day 3. Cycles were repeated every 4 weeks.

RESULTS

Seventeen patients received 39 cycles of treatment: median 2, (range 1-5). The tumors included glioblastoma (6), anaplastic astrocytoma (2), metastatic non-small cell (3), small cell lung (2), and one each with medulloblastoma, ependymoma, and metastatic breast or colon carcinoma. The median Karnofsky performance status was 70% (range 60-90%) and age: 52 (range 24-75). Eleven patients were female and six male. Toxicities included thrombocytopenia (2), neutropenia without fever lasting 6 days (1), DVT (2), and emesis (1). Topotecan levels, total and lactone, were measured prior to the end of infusion in plasma and cerebrospinal fluid (CSF). At 1.0 mg/m(2)/d, the median CSF/plasma ratio was 19.4% (range 15.1-59.1%). The total plasma topotecan in two pts with DLTs was 4.63 and 5.87 ng/ml, in three without DLTs at the same dose level the mean total plasma topotecan was 3.4 ng/ml (range 3.02-3.83). Plasma lactone levels were 33% of the total; CSF penetration was 20% of the total plasma levels. 4/8 pts with high-grade gliomas had stable disease (median: 3 cycles (range 2-5)). Two had minor responses. One patient with metastatic non-small cell and one with small cell lung cancer had objective PRs.

CONCLUSIONS

The recommended phase II doses are: tamoxifen 100 mg po bid, topotecan 0.75 mg/m(2)/d IV continuous infusion for 72 h, followed by carboplatin AUC = 3 IV on day 3. Measurable topotecan levels, both total and lactone, are observed in the CSF.

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.

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

BACKGROUND

Central nervous system (CNS) metastases from an ovarian malignancy are uncommon. The long-term prognosis for these patients is poor, with studies reporting a mean survival of less than 12 months.

CASES

We present three ovarian cancer patients who developed metastatic disease to the brain. All patients were heavily pre-treated prior to the development of CNS disease. Following detection of CNS disease, they all were treated with multi-modality therapy including gamma-knife radiosurgery (GKRS). At this time, one patient is alive at 26 months following treatment with GKRS. The second and third patients survived for 88 and 22 months respectively, before succumbing to their disease.

CONCLUSION

Local control of ovarian cancer metastatic to the brain can be achieved in some patients with GKRS. Additional investigation into GKRS is warranted.

CNS Metastases in Breast Cancer

As systemic therapy of metastatic breast cancer improves, CNS involvement is becoming a more widespread problem. This article summarizes the current knowledge regarding the incidence, clinical presentation, diagnosis, prognosis, and treatment of CNS metastases in patients with breast cancer. When available, studies specific to breast cancer are presented; in studies in which many solid tumors were evaluated together, the proportion of patients with breast cancer is noted. On the basis of data from randomized trials and retrospective series, neurosurgery and stereotactic radiosurgery (SRS) may prolong survival in patients with single brain metastases. The treatment of multiple metastases remains controversial, as does the routine use of whole-brain radiotherapy (WBRT) after either surgery or SRS. Although it is widely assumed that chemotherapy is of limited benefit, data from case series and case reports suggest otherwise. WBRT, neurosurgery, SRS, and medical therapy each have a role in the treatment of CNS metastases; however, neurologic symptoms frequently are not fully reversible, even with appropriate therapy. Studies specifically targeted toward this group of patients are needed.

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.

Long-term survival in an ovarian cancer patient with brain metastases

BACKGROUND

Central nervous system (CNS) metastases from ovarian adenocarcinoma are uncommon. The long-term prognosis for these patients is poor, with studies reporting a mean survival of less than 12 months.

CASE

We present a case involving a 57-year-old woman diagnosed and treated for primary ovarian cancer in 1994. She underwent optimal cytoreductive surgery and received adjuvant chemotherapy. In 1996, she was diagnosed with a right cerebellar metastatic lesion, and treated with surgery and whole-brain radiotherapy. She is currently 7 years post-treatment of her brain metastasis without evidence of recurrent disease.

CONCLUSION

Brain metastases from primary ovarian cancer are a relatively rare finding. These patients have a poor prognosis, with studies reporting a mean survival of 12 months. However, the patient in this report remains disease-free since her treatment for metastatic disease. Aggressive surgical and radiation treatment for patients with isolated CNS metastases is reasonable.

A case of ovarian cancer with remote metastases, with emphasis on changes in tumor marker values

BACKGROUND

The prognosis of cancer patients with distant metastases is extremely poor.

CASE

A 51-year-old Japanese woman with Stage IIIc serous cystoadenocarcinoma of the ovary achieved complete remission. At 30 and 39 months after the initiation of therapy, solitary brain and then spleen metastases without intraperitoneal lesions were found, respectively. A simultaneous elevation in tumor markers (CA125 and CA72-4) was noted at the spleen metastasis; however, only a marked elevation in CA 72-4 levels at the brain metastasis was noted. Immunohistochemical studies revealed that although CA125-positive cells could be observed in both the original tumor and the spleen metastasis, CA125-positive cells could not be observed in the brain metastasis and that CA72-4-positive cells could be observed in both the original ovarian tumor and the metastatic tumor.

CONCLUSION

It is important to monitor with tumor markers with different characteristics, such as CA125 and CA72-4.

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.

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.

Brain metastases

Brain metastases are an increasingly common complication in patients with systemic cancer. The optimal treatment for each patient depends on careful evaluation of several factors: the location, size, and number of brain metastases; the patient's age, general condition, and neurologic status; and the extent of systemic cancer to name a few. For patients with a single brain metastasis and limited systemic disease, the standard treatment is surgical resection followed by whole brain radiation therapy. In patients with a small, single metastasis, stereotactic radiosurgery is probably comparable to surgery. Patients with several metastases (up to three) and controlled systemic disease can be treated with whole-brain radiation and stereotactic radiosurgery. Patients with multiple metastases (more than three) are generally treated with whole-brain radiation alone. Radiosurgery is effective in treating patients with a limited number of recurrent brain metastases and stable systemic diseases. Surgery may have a role in patients with a large symptomatic recurrent lesion producing mass effect. Reirradiation and chemotherapy may have a limited role in patients with multiple recurrent metastases.

Brain metastases from epithelial ovarian carcinoma

BACKGROUND: Brain metastases from epithelial ovarian carcinoma are rare. We reviewed our experience to evaluate the results of different treatments and their prognosis. Discussion is based on a review of the literature. METHODS: From 1974 to 1998, eight of 704 patients treated for epithelial ovarian carcinoma at our large cancer center developed brain metastases. The median time before occurrence of brain metastases was 15 months after the diagnosis of the ovarian cancer. Six patients had a single lesion and two had multiple parenchymal lesions. Brain was the only site of disease in one patient, while seven had concomitant dissemination. Seven out of eight patients underwent a treatment for brain metastases. The treatment consisted of either radiotherapy (2 cases), chemotherapy (2 cases), surgery and radiotherapy (1 case), or combined treatment of the three modalities (2 cases). RESULTS: Median survival from diagnosis of brain lesions was 3 months (range 1-12). One patient without treatment died one month later. Survival after complete surgical resection and radiotherapy was 12 months. One patient treated by complete surgical resection followed by radiotherapy and chemotherapy is still alive (+ 5 months). The patient who underwent partial surgical resection followed by radiotherapy and chemotherapy died 7 months later. Two patients treated by radiotherapy alone died, respectively, 2 and 3 months later. After systemic chemotherapy alone, survival times were 1 and 3 months. Conclusions. The prognosis of patients with brain metastases from ovarian carcinoma is poor. A better outcome might be obtained by a multimodal treatment.

Mediastinal metastasis of ovarian carcinoma

Mediastinal metastasis of ovarian tumors are not rare as autopsy findings. Ovarian carcinomas usually spread by transcaelomic, lymphatic or haematogenous dissemination to peritoneum, pelvic and para-aortic lymph nodes, lung and pleura. A case of mediastinal metastasis of ovarian carcinoma is reported. A retrosternal mass was identified by CT scan and resected by VTC surgery.