Evaluating the Efficacy of Perfusion MRI and Conventional MRI in Distinguishing Recurrent Cerebral Metastasis from Brain Radiation Necrosis

Differentiating recurrent cerebral metastasis (CM) from brain radiation necrosis (BRN) is pivotal for guiding appropriate treatment and prognostication. Despite advances in imaging techniques, however, accurately distinguishing these conditions non-invasively is still challenging. This single-center retrospective study reviewed 32 cases (28 patients) with confirmed cerebral metastases who underwent surgical excision of lesions initially diagnosed by MRI and/or MR perfusion scans from 1 January 2015 to 30 September 2020. Diagnostic accuracy was assessed by comparing imaging findings with postoperative histopathology. Conventional MRI accurately identified recurrent CM in 75% of cases. MR perfusion scans showed significantly higher mean maximum relative cerebral blood volume (max. rCBV) in metastasis cases, indicating its potential as a discriminative biomarker. No single imaging modality could definitively distinguish CM from BRN. Survival analysis revealed gender as the only significant factor affecting overall survival, with no significant survival difference observed between patients with CM and BRN after controlling for confounding factors. This study underscores the limitations of both conventional MRI and MR perfusion scans in differentiating recurrent CM from BRN. Histopathological examination remains essential for accurate diagnosis. Further research is needed to improve the reliability of non-invasive imaging and to guide the management of patients with these post-radiation events.

Angiomatoid fibrous histiocytoma: primary intracranial lesion with thoracic spine metastasis and a malignant course. Illustrative case

BACKGROUND

Angiomatoid fibrous histiocytoma (AFH) is an exceptionally rare soft tissue neoplasm. This tumor primarily presents as a benign soft tissue lesion in children with an average age of 14 years. The standard treatment regimen is wide local excision with interval follow-up. However, newer reports have demonstrated malignant potential with the possibility of intracranial metastasis.

OBSERVATIONS

A 45-year-old male with no soft tissue primary tumor presented with a primary intracranial lesion and thoracic spine metastasis refractory to chemotherapy and radiation treatment.

LESSONS

This report illustrates the potential for a highly malignant nature of metastatic AFH. In addition, the authors demonstrate an incidence of AFH in a middle-aged male without a primary soft tissue or skin lesion. This report highlights the importance of prompt treatment and excision for AFH, as there is still little understanding of successful options for systemic therapy.

Retrospective Evaluation of Cases Undergoing Stereotaxic Brain Biopsy

Objective:  The aim of this study is to evaluate the demographic, radiological and histopathological findings, tumoral biomarkers, and survival rates of patients who underwent a stereotactic brain biopsy and those diagnosed with glioblastoma, metastasis, and lymphoma, and the changes in the diagnosis distribution over the years. Materials and Methods:  The patients who underwent stereotactic biopsy in our clinic between 2012 and 2020 were evaluated retrospectively. Metastasis, glioblastoma, and lymphoma cases were evaluated as three main groups and the others were excluded. P53 gene expression, isocitrate dehydrogenase (IDH) mutation, and Ki-67 values in glioblastoma cases and Bcl-2, Bcl-6 proteins, and Ki-67 values in lymphomas and their relationship with survival were evaluated. Results:  High p53 expression was observed in 27.5% cases diagnosed with glioblastoma. IDH mutation was negative in all glioblastoma cases. Presence of Bcl-2 and Bcl-6 proteins was not associated with survival in lymphomas. Survival rate was significantly higher in cases diagnosed with lymphoma (26.9%) compared to those diagnosed with glioblastoma. A statistically significant increase was determined in patients diagnosed with lymphoma considering the distribution of diseases and incidence and in the distribution of other diagnoses over the years ( p  < 0.05). Conclusion:  As per the distribution of the disease in recent times, it has been observed that there is an increase in lymphoma cases. Histopathology and biomarkers have great importance in the diagnosis and treatment of cerebral lesions. We think that our findings will be supported by studies in which larger patient population and detailed biomarkers will be studied.

Metastatic Progression of an Aggressive Hepatoblastoma Involving the Left Atrium and Ventricle

Hepatoblastoma is the most common malignant liver tumor in early childhood. The metastatic extension of hepatoblastoma into the left atrium via the pulmonary vein and left ventricle is rare. Reported cases almost always involve right-sided approaches and occur in pediatric patients. However, we are reporting a case of a 22-year-old female with recurrent hepatoblastoma at multiple sites, including the left atrium, left ventricle, brain, and lung.

Diffusion Microstructure Imaging to Analyze Perilesional T2 Signal Changes in Brain Metastases and Glioblastomas

Purpose: Glioblastomas (GBM) and brain metastases are often difficult to differentiate in conventional MRI. Diffusion microstructure imaging (DMI) is a novel MR technique that allows the approximation of the distribution of the intra-axonal compartment, the extra-axonal cellular, and the compartment of interstitial/free water within the white matter. We hypothesize that alterations in the T2 hyperintense areas surrounding contrast-enhancing tumor components may be used to differentiate GBM from metastases. Methods: DMI was performed in 19 patients with glioblastomas and 17 with metastatic lesions. DMI metrics were obtained from the T2 hyperintense areas surrounding contrast-enhancing tumor components. Resected brain tissue was assessed in six patients in each group for features of an edema pattern and tumor infiltration in the perilesional interstitium. Results: Within the perimetastatic T2 hyperintensities, we observed a significant increase in free water (p < 0.001) and a decrease in both the intra-axonal (p = 0.006) and extra-axonal compartments (p = 0.024) compared to GBM. Perilesional free water fraction was discriminative regarding the presence of GBM vs. metastasis with a ROC AUC of 0.824. Histologically, features of perilesional edema were present in all assessed metastases and absent or marginal in GBM. Conclusion: Perilesional T2 hyperintensities in brain metastases and GBM differ significantly in DMI-values. The increased free water fraction in brain metastases suits the histopathologically based hypothesis of perimetastatic vasogenic edema, whereas in glioblastomas there is additional tumor infiltration.

In vivo two-photon characterization of tumor-associated macrophages and microglia (TAM/M) and CX3CR1 during different steps of brain metastasis formation from lung cancer

Brain metastases frequently occur in lung cancer and dramatically limit prognosis of affected patients. The influence of tumor-associated macrophages and microglia (TAM/M) and their receptor CX3CR1 on different steps of brain metastasis formation from lung cancer is poorly characterized. We established a syngeneic orthotopic cerebral metastasis model in mice by combining a chronic cranial window with repetitive intravital 2-photon laser scanning microscopy. This allowed in vivo tracking of fluorescence-expressing tumor cells and TAM/M on a single-cell level over weeks. Intracarotid injection of red tdTomato-fluorescent Lewis lung carcinoma cell was performed in transgenic mice either proficient or deficient for CX3CR1. After intracarotid cell injection, intravascular tumor cells extravasated into the brain parenchyma and formed micro- and mature macrometastases. We observed potential phagocytosis of extravasated tumor cells by TAM/M. However, during later steps of metastasis formation, these anti-tumor effects diminished and were paralleled by TAM/M accumulation and activation. Although CX3CR1 deficiency resulted in a lower number of extravasated tumor cells, progression of these extravasated cells into micro metastases was more efficient. Overall, this resulted in a comparable number of mature macrometastases in CX3CR1-deficient and -proficient mice. Our findings indicate that unspecific inhibition of CX3CR1 might not be a suitable therapeutic option to prevent dissemination of lung cancer cells to the brain. Given the close interaction between TAM/M and tumor cells during metastasis formation, other therapeutic approaches targeting TAM/M function may warrant further evaluation. The herein established orthotopic mouse model may be a useful tool to evaluate such concepts in vivo.

TAMs in Brain Metastasis: Molecular Signatures in Mouse and Man

Macrophages not only represent an integral part of innate immunity but also critically contribute to tissue and organ homeostasis. Moreover, disease progression is accompanied by macrophage accumulation in many cancer types and is often associated with poor prognosis and therapy resistance. Given their critical role in modulating tumor immunity in primary and metastatic brain cancers, macrophages are emerging as promising therapeutic targets. Different types of macrophages infiltrate brain cancers, including (i) CNS resident macrophages that comprise microglia (TAM-MG) as well as border-associated macrophages and (ii) monocyte-derived macrophages (TAM-MDM) that are recruited from the periphery. Controversy remained about their disease-associated functions since classical approaches did not reliably distinguish between macrophage subpopulations. Recent conceptual and technological advances, such as large-scale omic approaches, provided new insight into molecular profiles of TAMs based on their cellular origin. In this review, we summarize insight from recent studies highlighting similarities and differences of TAM-MG and TAM-MDM at the molecular level. We will focus on data obtained from RNA sequencing and mass cytometry approaches. Together, this knowledge significantly contributes to our understanding of transcriptional and translational programs that define disease-associated TAM functions. Cross-species meta-analyses will further help to evaluate the translational significance of preclinical findings as part of the effort to identify candidates for macrophage-targeted therapy against brain metastasis.

Phase III randomized study of carboplatin pemetrexed with or without bevacizumab with initial versus "at progression" cerebral radiotherapy in advanced non squamous non-small cell lung cancer with asymptomatic brain metastasis

Background:

The role and timing of whole or stereotaxic brain radiotherapy (BR) in patients with advanced non-small cell lung cancer (aNSCLC) and asymptomatic brain metastases (aBMs) are not well established. This study investigates whether deferring BR until cerebral progression was superior to upfront BR for patients with aNSCLC and aBM.

Methods:

This open-label, multicenter, phase III trial, randomized (1:1) aNSCLC patients with aBMs to receive upfront BR and chemotherapy: platin–pemetrexed and bevacizumab in eligible patients, followed by maintenance pemetrexed with or without bevacizumab, BR arm, or the same chemotherapy with BR only at cerebral progression, chemotherapy (ChT) arm. Primary endpoint was progression-free survival (PFS), secondary endpoints were overall survival (OS), global, extra-cerebral and cerebral objective response rate (ORR), toxicity, and quality of life [ClinicalTrials.gov identifier: NCT02162537].

Results:

The trial was stopped early because of slow recruitment. Among 95 included patients, 91 were randomized in 24 centers: 45 to BR and 46 to ChT arms (age: 60 ± 8.1, men: 79%, PS 0/1: 51.7%/48.3%; adenocarcinomas: 92.2%, extra-cerebral metastases: 57.8%, without differences between arms.) Significantly more patients in the BR-arm received BR compare with those in the ChT arm (87% versus 20%; p < 0.001); there were no significant differences between BR and ChT arms for median PFS: 4.7, 95% confidence interval (CI):3.4–7.5 versus 4.8, 95% CI: 2.4–6.5 months, for median OS: 8.5, 95% CI:.6–11.1 versus 8.3, 95% CI:4.5–11.5 months, cerebral and extra-cerebral ORR (27% versus 13%, p = 0.064, and 30% versus 41%, p = 0.245, respectively). The ChT arm had more grade 3/4 neutropenia than the BR arm (13% versus 6%, p = 0.045); others toxicities were comparable.

Conclusion:

The significant BR rate difference between the two arms suggests that upfront BR is not mandatory in aNSCLC with aBM but this trial failed to show that deferring BR for aBM is superior in terms of PFS from upfront BR.

Pre-Treatment Seizures in Patients With 1-3 Cerebral Metastases Receiving Local Therapies Plus Whole-brain Radiotherapy

BACKGROUND/AIM

Seizures impair patients' quality of life. The prognostic role of pre-treatment seizures in patients with 1-3 cerebral metastases receiving local therapies plus whole-brain radiotherapy (WBRT) was investigated.

PATIENTS AND METHODS

In 249 patients, prevalence, risk factors and associations of pre-treatment seizures with survival were retrospectively evaluated. Age, gender, performance score, tumor type, number of lesions, extra-cerebral metastases, and time from tumor diagnosis to treatment of cerebral metastasis were analyzed for associations with seizures. These characteristics and pre-treatment seizures were also analyzed for associations with survival.

RESULTS

The prevalence of pre-treatment seizures was 24.1%. Trends for associations were found between seizures and gender or performance score. On multivariate analysis, age (p=0.008), performance score (p=0.004), tumor type (p<0.001) and extra-cerebral metastasis (p<0.001) were significantly associated with survival.

CONCLUSION

Seizures were comparably common prior to local therapies plus WBRT for cerebral metastases. No factor was found to be significantly associated with seizures, and seizures were not associated with survival.

Prognostic value and impact of cerebral metastases in pancreatic cancer

Background: Pancreatic cancer is a fatal disease most often diagnosed at an advanced stage. Most patients already suffer from irresectable tumor or distant metastases being most commonly found in the liver or the lung. However, cerebral metastases occur extremely rare.Methods: We performed a retrospective analysis of our database to identify all patients diagnosed with pancreatic cancer and cerebral metastases who underwent surgical treatment in our department from January 2004 to November 2016.Results: Only 0.2% (4 of 2492) were diagnosed with cerebral metastases. Two patients had surgical resection of the cerebral metastases. One patient underwent palliative radiation therapy and the fourth patient received only palliative therapy. Mean interval between initial diagnosis and development of brain metastases was 8.5 months (range 1-20). Mean survival period after diagnosis of brain metastases was 4.75 months (range 1-10).Conclusions: Cerebral metastases of pancreatic cancer occur extremely rare. They are associated with an advanced tumor stage, commonly liver and lung metastases. All patients presenting with neurological symptoms, multifocal metastases, and significantly elevated CA 19-9 levels are suspicious of sustaining cerebral metastases and should undergo brain imaging.

Solitary Cerebral Metastases vs. High-grade Gliomas: Usefulness of Two MRI Signs in the Differential Diagnosis

BACKGROUND/AIM

The differentiation between cerebral metastases (CM) and high-grade gliomas (HGG) can be difficult on magnetic resonance imaging (MRI). The aim of this study was to evaluate the usefulness of searching two MRI signs (signal alteration in the adjacent cortex, SAAC, and peripheral rim sign, PRS), in order to distinguish between these entities.

PATIENTS AND METHODS

A total of 61 patients were retrospectively enrolled (28 HGG, 33 CM). Fluid Attenuated Inversion Recovery (FLAIR) sequences were used to assess SAAC and contrast-enhanced T1-weighted sequences for PRS.

RESULTS

A positive SAAC sign was present in 61% of HGG, and 12% of CM. Conversely, in SAAC-negative lesions, PRS was observed in 78% of CM and in 32% of HGG. Their association had a higher frequency in HGG than in the CM group (21 vs. 3%).

CONCLUSION

While SAAC is specific for HGG and PRS, in the absence of SAAC, is relatively specific for CMs, their combined presence is highly suggestive of HGG.

Intraventricular metastases from rectal carcinoma: case report and literature review

Intraventricular metastases are a rare occurrence, particularly from a primary colorectal malignancy. To our knowledge, this is the first report of intraventricular metastasis from rectal cancer. A 72-year-old male presented with a new diagnosis of multiple intraventricular lesions, an anterior mediastinal mass and a rectal mass. His workup revealed rectal adenocarcinoma with intraventricular metastases and an incidental thymoma. Ommaya reservoir placement was performed via an awake procedure rather than under general anesthesia due to airway concerns. Cerebrospinal fluid (CSF) cytology was positive for malignancy and consistent with adenocarcinoma. Two weeks postoperatively, the patient underwent whole brain radiation. Although rare, this diagnosis should always be considered in the differential for solitary or multiple intraventricular lesions. CSF sampling is a useful alternative to intraventricular biopsy for diagnosis of intraventricular metastases. Awake placement of Ommaya reservoir is a safe option in the management of patients with intraventricular metastases, especially those who cannot undergo general anesthesia.

Predictive Factors for Local Control and Survival in Patients with Cancer of Unknown Primary (CUP) Irradiated for Cerebral Metastases

BACKGROUND/AIM

To identify predictors of local control and survival after whole-brain irradiation (WBI) for cerebral metastases from cancer of unknown primary (CUP).

PATIENTS AND METHODS

In 140 patients receiving WBI alone or following resection, seven factors were investigated including treatment approach, WBI-regimen, age, gender, Eastern Cooperative Oncology Group (ECOG) performance score, number of cerebral lesions and extra-cerebral metastases.

RESULTS

On univariate analysis, resection plus WBI and boost (p=0.002), ECOG 0-1 (p<0.001) and a single lesion (p<0.001) were positively associated with local control. On Cox regression, ECOG-score remained significant (p=0.002). On univariate analysis of survival, surgery plus WBI and boost (p=0.009), ECOG 0-1 (p<0.001), a single lesion (p=0.024) and no extra-cerebral metastases (p<0.001) were associated with better outcomes. On Cox regression, ECOG-score (p<0.001) and extra-cerebral lesions (p<0.001) were significant.

CONCLUSION

Significant predictors of local control and survival were identified that contribute to treatment personalization and design of prospective trials in patients with cerebral metastases from CUP.

[Effective systemic palliative chemotherapy for intracranial metastases of breast cancer]

The authors present the history of two patients. The first patient, a 69-year-old woman was diagnosed with locally invasive triple negative breast cancer with pulmonary and cerebral metastases. Complete radiological remission of the clinically asymptomatic cerebral metastases was detected under systemic chemotherapy with carboplatin-docetaxel (75 mg/m²). Later, the patient received whole brain radiotherapy and a second line of chemotherapy. The overall survival was 20 months from the diagnosis of cerebral metastases with conservation of partial autonomy. The second patient, a 57-year-old woman was diagnosed as having hormone sensitive lobular breast cancer with leptomeningeal, lymphonodular and multiple osseal metastases. Before the appearance of the lymphonodular metastasis the patient received intrathecal methotrexate chemotherapy for the leptomeningeal carcinomatosis. Her neurological symptoms completely disappeared. At the onset of the lymphonodular metastasis systemic chemotherapy with ifosfamide (1000 mg/m², D1-3) - etoposide (100 mg/m², D1-3) was started allowing complete clinical remission of the lymphadenomegaly and stability of the asymptomatic neurological status. The overall survival was 13 months from the diagnosis of leptomeningeal carcinomatosis with conservation of autonomy. The two cases support potential efficacy of systemic chemotherapy for intracranial metastases of breast cancer. Orv. Hetil., 2016, 157(45), 1809-1813.

Metastatic Prostate Adenocarcinoma to the Brain: Case Reports and Literature Review

Cerebral metastasis secondary to prostatic adenocarcinoma is rare and it is usually a late complication in patients with widespread distant metastases. Here, we report two unusual cases of such a rare condition. Our first case presented with a large frontal contrast-enhancing lesion-associated calcification and a large tumor cyst as shown on computed tomography and magnetic resonance imaging. This is the fifth reported case of prostatic metastasis manifesting as a cystic intraparenchymal tumor in the literature. The second case presented with a large soft tissue mass in the scalp and this lesion appeared to invade through the skull and into the middle cranial fossa. He was not known to have prostate cancer before his initial presentation and it was only diagnosed following histology results of the scalp lesion.

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.

Estimating survival of patients receiving radiosurgery alone for cerebral metastasis from melanoma

This study aimed to identify clinical factors associated with survival and to develop a prognostic tool in patients receiving radiosurgery alone for very few cerebral metastases from melanoma. Ten characteristics of 69 patients treated with radiosurgery alone for 1-3 cerebral metastases from melanoma were retrospectively analyzed for survival. Serum lactate dehydrogenase levels before radiosurgery, Karnofsky performance score, maximum diameter of all irradiated cerebral lesions, and extracranial lesions were significantly associated with survival and included in the tool. Twelve-month survival rate (in %) divided by 10 was calculated for each of these four factors. The four scores were summed resulting in total scores ranging 9-22 points. Based on the 12-month survival rates, three groups were formed: less than 15 points (group I, n = 25); 15-20 points (group II, n = 34); and more than 20 points (group III, n = 10). Corresponding 12-month survival rates were 10 ± 6%, 51 ± 9% and 90 ± 9%, respectively (P < 0.001). In group I, death within 12 months following radiosurgery occurred mostly due to extracranial progression, whereas cerebral progression was the major cause of death in group II. In group III, only one of 10 patients died within 1 year. This new prognostic tool helps predict the survival time following radiosurgery of very few cerebral metastases from melanoma. An individual treatment approach should consider a patient's survival time and the most likely cause of death (cerebral or extracranial progression).

Isolated cerebral metastasis of a triceps muscle leiomyosarcoma: a case report

Leiomyosarcomas are rare malignant neoplasms. Intracranial metastases of this tumour are even less frequently observed and have mostly been described from uterine leiomyosarcomas. In this article, we describe the case of a single right frontal subcortical cerebral metastasis in a patient with a right triceps muscle leiomyosarcoma. A right-sided frontal craniotomy with macroscopically complete tumour removal was performed, followed by combined radio-chemotherapy. The patient died 10 months after the initial diagnosis of the intracranial metastasis due to systemic tumour progression, without any evidence of intracranial recurrence.

Seed, soil, and beyond: The basic biology of brain metastasis

First invoked by Paget, the seed and soil hypothesis suggests that the successful growth of metastatic cells depends on the interactions and properties of cancer cells (seeds) and their potential target organs (soil). In the context of the seed and soil hypothesis this review examines recent advances in the understanding of molecular and cellular features that permit transformed epithelial cells to gain access to the blood stream (intravasation), survive their journey through the blood stream, and ultimately traverse through the microvasculature of target organs (extravsation) to deposit, survive, and grow in a foreign tissue environment. In addition to a review of the clinical and experimental evidence supporting the seed and soil theory to cancer metastasis, additional concepts highlighted include: (i) The role of cancer stem-like cells as putative cells of metastatic origin (the "seeds"); (ii) the mechanism of epithelial to mesenchymal transition (EMT) in driving epithelial cell conthose molecules do no blood stream to avoid anoikis, or anchorage independent cell death; and (iv) the reverse process of EMT, or mesenchymal to epithelial transition (MET), which promotes conversion back to the parent cell morphology and growth of macrometastsis in the target organ. The unique biology of metastases once established in the brain, and in particular the "sanctuary" role that the brain microenvironment plays in promoting metastatic growth and treatment resistance, will also be examined. These issues are of more than academic interest since as systemic therapies gradually improve local tumor control, the relative impact of brain metastasis will inexorably play a proportionally greater role in determining patient morbidity and mortality.