Long-term survival after brain metastases from tracheal carcinoma

A case of prolonged survival after radiotherapy for primary tracheal squamous cell carcinoma and the subsequent brain metastases is reported. The patient is alive and well without any sign of relapse, approximately six years after the onset of brain metastases from tracheal carcinoma. Radiotherapy proved useful in the treatment of both the primary tracheal carcinoma and the brain metastases.     

Brain metastases from prostate adenocarcinoma

Brain metastases of prostate adenocarcinoma are rare. We report a case of brain metastases from prostate adenocarcinoma 15 months after the diagnosis of the primary tumour. The patient had headache and one solitary metastasis upon magnetic resonance imaging (MRI). The biopsy performed showed metastatic prostate adenocarcinoma. He was treated with surgery and cranial irradiation.     

Fractionated stereotactic radiotherapy of brain metastases from renal cell carcinoma

Purpose: To retrospectively evaluate the effectiveness of fractionated stereotactic radiotherapy (FSRT) for brain metastases from renal cell carcinoma (RCC).

Methods and Materials: From May 1983 to September 1998, 35 patients with brain metastases from RCC underwent radiotherapy at the National Cancer Center Hospital, Tokyo; 10 patients treated initially with FSRT (FSRT group); 11 with surgery followed by conventional radiotherapy (S/CR group); and 14 with conventional radiotherapy (CR group). Survival and local control rates were determined for patients who had an ECOG performance status of 0–2.

Results: Overall median survival rate was 18 months, and actuarial 1- and 2-year survival rates were 57.6% and 31.0%, respectively. Median survival rates were 25.6 months for the FSRT group, 18.7 months for the S/CR group, and 4.3 months for the CR group. Significant prognostic factors associated with survival were age less than 60 years and good performance status. In patients treated with FSRT, imaging studies revealed that 21 of 24 tumors (88%) were locally controlled during a median follow-up time of 5.2 months (range 0.5–68). Actuarial 1- and 2-year local control rates were 89.6% and 55.2%, respectively. No patient suffered from acute or late complications during and following FSRT.

Conclusions: FSRT offers better tumor control and prolonged survival over the S/CR or CR groups, and should be considered as primary treatment for brain metastases from RCC. Patients under 60-years-old and those with a good performance status at the beginning of radiotherapy had a better prognosis.     

单发或多发脑转移瘤的放疗疗效研究

目的 探求单发与多发脑转移瘤的合理放疗方案.方法 回顾性分析2005年7月至2008年7月收治的50例单发或多发脑转移瘤患者的资料.所有患者原发灶均得到控制,30例(联合组)采用全脑放疗+立体定向放射外科治疗,20例(单一组)采用单纯立体定向放射外科治疗.立体定向放射外科治疗处方剂量均采用45％～ 75％等剂量线包绕计划靶区,边缘剂量15～20 Gy,中心剂量30 ～45 Gy,一次完成;全脑放疗每次分割剂量为2 Gy,1次/d,5次/周,总剂量40 Gy/4周.结果 联合组有效率为90.0％ (27/30),单一组为60.0％ (12/20),联合组的有效率明显高于单一组(x2=6.294,P=0.012);联合组和单一组的1年生存率分别为50.0％ (15/30)和35.0％ (7/20),2年生存率分别为30.0％(9/30)和15.0％(3/20),两组1、2年生存率差异均无统计学意义(x2=1.096,P=0.295;x2=1.480,P=0.224),两组均无生存3年以上的患者;分层分析显示,在单发病灶患者中,两组1年生存率差异无统计学意义(100.0％∶66.7％,x2=1.556,P=0.212),在多发病灶患者中,联合组的1年生存率明显优于单一组(42.3％∶29.4％,x2 =11.023,P=0.001),在单发和多发病灶患者中,两组2年生存率差异均无统计学意义(75.0％∶66.7％,x2=1.200,P=0.273;23.1％∶5.9％,x2=3.782,P=0.052).结论 全脑放疗和立体定向放射外科是治疗单发或多发脑转移瘤的重要手段,对于单发脑转移瘤可单独行立体定向放射外科治疗,多发脑转移瘤则应行全脑放疗联合立体定向放射外科治疗.     

Stereotactic radiosurgery for four or more intracranial metastases

PURPOSE: To evaluate the outcomes after a single stereotactic radiosurgery procedure for the care of patients with 4 or more intracranial metastases. METHODS AND MATERIALS: Two hundred five patients with primary malignancies, including non-small-cell lung carcinoma (42%), breast carcinoma (23%), melanoma (17%), renal cell carcinoma (6%), colon cancer (3%), and others (10%) underwent gamma knife radiosurgery for 4 or more intracranial metastases at one time. The median number of brain metastases was 5 (range, 4-18) with a median total treatment volume of 6.8 cc (range, 0.6-51.0 cc). Radiosurgery was used as sole management (17% of patients), or in combination with whole brain radiotherapy (46%) or after failure of whole brain radiotherapy (38%). The median marginal radiosurgery dose was 16 Gy (range, 12-20 Gy). The mean follow-up was 8 months. RESULTS: The median overall survival after radiosurgery for all patients was 8 months. The 1-year local control rate was 71%, and the median time to progressive/new brain metastases was 9 months. Using the Radiation Therapy Oncology Group recursive partitioning analysis (RPA) classification system, the median overall survivals for RPA classes I, II, and III were 18, 9, and 3 months, respectively (p < 0.00001). Multivariate analysis revealed total treatment volume, age, RPA classification, and marginal dose as significant prognostic factors. The number of metastases was not statistically significant (p = 0.333). CONCLUSION: Radiosurgery seems to provide survival benefit for patients with 4 or more intracranial metastases. Because total treatment volume was the most significant predictor of survival, the total volume of brain metastases, rather than the number of metastases, should be considered in identifying appropriate radiosurgery candidates.     

Brain metastases from apocrine carcinoma of the scalp: case report

Summary Apocrine carcinoma is an extremely rare malignant neoplasm that occurs most frequently in the axilla. Although it usually shows an indolent clinical course, it often metastasizes to regional lymph nodes and sometimes to lungs or bones. However, a literature search did not reveal any report describing the detailed clinical course of brain metastases from apocrine carcinoma. We report a case of a 54-year-old male who suffered from multiple brain metastases from apocrine carcinoma that had originated in the scalp 6 years before. The brain metastases appeared in spite of several regimens of chemotherapy for lung metastases for two years. The tumor in the right frontal lobe was successfully operated. However, the small tumor in the right occipital lobe was not cured by gamma knife surgery, and eventually required second operation. The operation had contributed to his neurologically independent life for about one year until he died for gradual progression of lung metastases. To our knowledge this is the first reported case of metastatic brain tumor from apocrine carcinoma.     

8例肝癌脑转移病例分析

目的探讨肝癌脑转移病例的临床特点和治疗方法。方法回顾性分析1994年1月一2008年6月我院收治原发性肝癌发生脑转移患者的临床特点、治疗方法及生存期。结果本组共8例肝癌脑转移病例,其中7例为男性,中位发病年龄为50．0岁。5例患者有慢性乙型肝炎、肝硬化病史。患者血中甲胎蛋白含量7例〉1000ng／ml,并且2例〉10000ng／ml。头痛是最常见的首发症状（4／8）,3例患者出现头晕、轻偏瘫、感觉障碍,2例出现复视、意识障碍,1例出现构音障碍,6例患者同时伴有至少2种症状,5例患者同时伴有肺转移,4例患者在2个月内死亡。结论肝癌脑转移患者预后很差,其治疗模式有待积极探索。     

Brain metastases in breast cancer: clinical and pathologic characteristics associated with improvements in survival

BACKGROUND: As breast cancer patients live longer with control of systemic disease, survival after the diagnosis of brain metastases (BM) also appears to be improving. METHODS: The authors conducted a retrospective review of 112 breast cancer patients diagnosed with BM from 1997 to 2007 and correlated clinical and pathologic characteristics including hormone receptor (HR) and Her2/neu status with outcomes. FINDINGS: Median time to BM diagnosis (TTBM) was 38 months (range, 0-204 months). TTBM was shorter for patients with HR- versus HR+ disease (median 28.8 vs. 61.2 months, P < 0.001, Wilcoxon test). No difference in TTBM was observed for patients with HER2- versus HER2+ disease (median 37.4 vs. 34.9 months, P = 0.81). Median survival after the diagnosis of BM was 14.4 months. There was no significant difference in median survival after BM diagnosis for patients with HR+ versus HR- cancers (19.9 vs. 11.0 months, P = 0.18, log rank) or for patients with HER2+ versus HER2- disease (23.1 vs. 13.3 months, P = 0.11, log rank). Survival was significantly longer in patients with stable or responding systemic disease at BM diagnosis compared to patients with progressing systemic disease (31 vs. 6.3 months, P < 0.001). Multivariate analysis revealed that HR positivity, age <50, Karnofsky Performance Score (KPS) > or =80, and stable or responding systemic disease at BM diagnosis were associated with improved survival. INTERPRETATION: Subsets of patients with breast cancer BM are surviving longer. Control of systemic disease was most strongly associated with improved outcomes, and HER2/neu overexpression did not shorten survival after the diagnosis of BM.     

Ovarian metastases from colon carcinoma

A case report describes a postmenopausal woman who presented with vaginal bleeding and a pelvic mass. She was found to have a colon cancer with a large metastasis in the right ovary. A review of the literature suggests that ovarian metastasis from a primary colon carcinoma is not rare. Frequently, the ovarian tumor causes symptoms sooner than the primary carcinoma. The presence of ovarian metastasis is associated with a poor prognosis. Consideration should be given to the performance of prophylactic oophorectomy during colon resections for carcinoma.     

A comparison of surgical resection and stereotactic radiosurgery in the treatment of solitary brain metastases

PURPOSE: To determine whether neurosurgery (NS) or stereotactic radiosurgery (RS) provided better local tumor control and enhanced patient survival. METHODS AND MATERIALS: Retrospective review of all solitary brain metastases (SBM) patients newly diagnosed at Mayo Clinic Rochester between 1991 and 1999. Eligible patients satisfied tumor size and SBM site criteria to qualify for both NS and RS. RESULTS: There were no significant differences between 74 NS and 23 RS patients in terms of baseline characteristics (age, gender, systemic disease type, systemic disease status, signs/symptoms at SBM presentation) or percent of patients who received whole brain radiotherapy. Median follow-up for alive patients was 20 months (range 0-106 months). There was no significant difference in patient survival (p = 0.15); the 1-year survival rate was 56% for the RS patients and 62% for the NS patients. Multivariate Cox regression analysis found that a significant prognostic factor for survival was a performance score of 0 or 1. There was a significant (p = 0.020) difference in local tumor control between NS and RS for solitary brain metastasis; none of the RS group had local recurrence compared to 19 (58%) of the NS group. CONCLUSION: The need for a Phase III study comparing these two techniques appears to be supported by the data from this study.     

Ocular metastases from breast carcinoma

Intraocular metastases are the most common malignancy of the eye, and the primary cause is breast cancer. This is a retrospective analysis, which reports the clinical experience of eye metastases in 16 patients during the period of January, 1991, to December, 2002, who attended a tertiary referral center in Mexico City. Mean age at diagnosis was 40 yr (range 24–58). Most of patients were initially in clinical stage IIB-IV. Median time from breast cancer diagnosis to development of ocular metastases was 22.5 mo and from metastatic disease to ocular metastases was 10 mo. Ocular symptoms were decrease of visual acuity, ocular pain, nonspecific symptoms, proptosis, and palpebral edema. Three patients had bilateral ocular metastases. Fourteen patients were treated with radiation, and clinical response was documented in 4/15 eyes; ocular pain responded in three patients with this symptom. No ocular enucleations were performed. One patient developed glaucoma. No other major toxicities were documented. Median survival time was 26 mo and 25% of our patients were alive at a maximum follow-up of 90 mo. This entity requires early recognition in order to preserve the visual function and quality of life of patients with breast cancer, since their prognosis has improved in recent years.     

Osteoblastic bone metastases from renal cell carcinoma

Background

RCC accounts for only 2–3% of all cancers. Due to its’ non-specific symptoms disease is often diagnosed in advanced stage. Disseminated RCC frequently produces bone metastases that are almost always highly destructive, hyper vascularized and purely osteolytic.

Case report.

In this article we describe a case of a 71-year old male patient with disseminated osteoblastic bone metastases from renal cell carcinoma (RCC), and present a short review of published literature reporting cases of osteoblastic bone metastases from RCC. Our patient presented with thoracic pain aggravated by movement. He was diagnosed with predominantly osteoblastic bone metastases in the skeleton of thoracic and lumbar vertebra along with metastases in iliac bones, ribs, humerus and clavicles. Initially, origin of bone metastases was unknown, but later a small tumor in patient’s right kidney was identified. Microscopic evaluation of the open bone biopsy showed clear cell RCC with sarcomatoid differentiation.

Conclusions

Although, due to its’ rarity, RCC is not included in the primary differential diagnosis in patients with osteoblastic metastases, such rare cases suggest that RCC may be considered in the diagnosis when there no other primary tumor is found.     

Radiotherapy of carcinoma of the uterine cervix in Singapore, 1973-1975

The results of 322 patients with uterine cervix carcinoma treated by radiotherapy at the Singapore General Hospital in the 3-year period from 1973 to 75 are presented. Two hundred seventy-nine patients were treated with a combination of intracavitary radium, using Fletcher-Suit applicators and cobalt teletherapy; the remaining 43 patients received only cobalt teletherapy. One hundred thirty-four patients (41.6%) presented with FIGO Stage III disease. Only 46 patients (14.3%) presented with Stage I disease, showing that patients tended to present late in the disease course. Five-year actuarial (uncorrected) survival rates of 86.7% for Stage I, 65.0% for Stage II, 41.4% for Stage III and 4.9% for Stage IV were obtained with corresponding 10 year rates of 79.6%, 60.2%, 35.2% and 0%. The overall 5 and 10 year survival rates were 54.0% and 48.2%, respectively. The survival rates "flattened off" at about 7-8 years, reflecting late deaths after the fifth anniversary of treatment. Non-severe complications consisted mainly of chronic proctitis (41.3%) and vaginal stenosis (20.8%). Major complications were intestinal stricture (1.2%) and fistula formation (1.6%).     

Transient enlargement of contrast uptake on MRI after linear accelerator (linac) stereotactic radiosurgery for brain metastases

Purpose/Objective: With the increasing number of patients successfully treated with stereotactic radiosurgery for brain metastases, decision making after therapy based on follow-up imaging findings becomes more and more important. Magnetic resonance imaging (MRI) is the most sensitive means for follow-up studies. The objective of this study was to investigate the treatment outcome of our radiosurgery program and to describe the response of brain metastases to contrast-enhanced MRI after linear accelerator (linac) stereotactic radiosurgery and identify factors to distinguish among local control and local failure.

Methods and Materials: Using serial MRI, we followed the course of 87 brain metastases in 48 consecutive patients treated between September 1996 and November 1997 with linac-based radiosurgery with 15-MV photons. Treatment planning was performed on an MR data cube. For spherical metastases, radiosurgery was delivered using a 9 noncoplanar arc technique with circular-shaped collimators. For irregularly shaped targets, radiosurgery was delivered using a manually driven multi-leaf collimator with a leaf width of 1.5 mm projected to the isocenter. Median radiosurgery dose was 20 Gy prescribed to the 80% isodose. Together with whole brain radiotherapy (20 × 2 Gy, 5/w), a median radiosurgical dose of 15 Gy was delivered. Median follow-up was 8 (range 2–36) months. Factors influencing local control and survival rates were analyzed with respect to MRI response, and Kaplan-Meier curves were calculated.

Results: Actuarial local tumor control was 91% at one and two years. Patient survival at one and two years was 30% and 18%. Median survival was 9 months. During follow-up in 70 (81%) of the 87 treated metastases, the contrast-enhancing volumes on T1W images were stable or disappeared partly or completely. A transient enlargement of contrast-enhancing volumes was observed in 11 (12%) of the 87 lesions treated, while a progressive enlargement due to local treatment failure was observed in 6 (7%) of the 87 treated metastases. Younger age, early contrast onset after radiosurgery, and previous chemotherapy were associated with this transient enlargement of contrast-enhancing lesion volume.

Conclusions: Linac-based radiosurgery is an effective, noninvasive, and safe treatment option for patients with brain metastases. A marked enlargement of the contrast-enhancing volume on T₁-weighted MR images after radiosurgery is a sensitive predictor for, but not equivalent with, local failure. In as many as two-thirds of the cases with contrast enlargement in MRI follow-up, the contrast enlargement is transient with no need for further treatment. While some MRI findings are more likely if transient enlargement is present, a clear decision cannot be made based on MRI, and ultimately the clinical status dictates further action.     

Glassy cell carcinoma of the uterine cervix responsive to neoadjuvant intraarterial chemotherapy

Described as a poorly differentiated adenosquamous cancer, glassy cell carcinoma of the uterine cervix is a rare disease considered to have an extremely poor prognosis. Saitama Medical Center has been offering neoadjuvant intraarterial chemotherapy (NAC) to cervical cancer patients as a means of avoiding postoperative radiation therapy, achieving downstaging, and improving prognosis. We report a patient with glassy cell carcinoma of the uterine cervix who responded to NAC, and we discuss this case with reference to reports in the literature. A 28-year-old gravida 1, para 0 patient was referred to the Department of Obstetrics and Gynecology at Saitama Medical Center for concurrent cervical cancer at 23.5 gestational weeks. The patient was admitted to our center following the diagnosis of stage IIb cervical cancer (glassy cell carcinoma), to await fetal development, and an elective cesarean section was performed at slightly more than 29 gestational weeks. Three cycles of NAC with carboplatin (CBDCA)/etoposide/epirubicin, started 3 days after the operation, shrank the tumor remarkably. An extended radical hysterectomy was subsequently performed. It has been 6 years, to date, since the initial treatment, and our patient is alive and disease/recurrence free.     

Radiosurgery for brain metastases: a score index for predicting prognosis

Purpose: To analyze a prognostic score index for patients with brain metastases submitted to stereotactic radiosurgery (the Score Index for Radiosurgery in Brain Metastases [SIR]).

Methods and Materials: Actuarial survival of 65 brain metastases patients treated with radiosurgery between July 1993 and December 1997 was retrospectively analyzed. Prognostic factors included age, Karnofsky performance status (KPS), extracranial disease status, number of brain lesions, largest brain lesion volume, lesions site, and receiving or not whole brain irradiation. The SIR was obtained through summation of the previously noted first five prognostic factors. Kaplan-Meier actuarial survival curves for all prognostic factors, SIR, and recursive partitioning analysis (RPA) (RTOG prognostic score) were calculated. Survival curves of subsets were compared by log-rank test. Application of the Cox model was utilized to identify any correlation between prognostic factors, prognostic scores, and survival.

Results: Median overall survival from radiosurgery was 6.8 months. Utilizing univariate analysis, extracranial disease status, KPS, number of brain lesions, largest brain lesion volume, RPA, and SIR were significantly correlated with prognosis. Median survival for the RPA classes 1, 2, and 3 was 20.19 months, 7.75 months, and 3.38 months respectively (p = 0.0131). Median survival for patients, grouped under SIR from 1 to 3, 4 to 7, and 8 to 10, was 2.91 months, 7.00 months, and 31.38 months respectively (p = 0.0001). Using the Cox model, extracranial disease status and KPS demonstrated significant correlation with prognosis (p = 0.0001 and 0.0004 respectively). Multivariate analysis also demonstrated significance for SIR and RPA when tested individually (p = 0.0001 and 0.0040 respectively). Applying the Cox Model to both SIR and RPA, only SIR reached independent significance (p = 0.0004).

Conclusions: Systemic disease status, KPS, SIR, and RPA are reliable prognostic factors for patients with brain metastases submitted to radiosurgery. Applying SIR and RPA classifications to our patients’ data, SIR demonstrated better accuracy in predicting prognosis. SIR should be further tested with larger patient accrual and for all patients with brain metastases subjected or not to stereotactic radiosurgery.