ORIGINAL ARTICLE pISSN 2288-6575 • eISSN 2288-6796 https://doi.org/10.4174/astr.2018.94.1.13 Annals of Surgical Treatment and Research
Brain metastasis from colorectal cancer: a single center experience Dong-Yeop Kim, Chun-Geun Ryu, Eun-Joo Jung, Jin-Hee Paik, Dae-Yong Hwang Department of Surgery, Colorectal Cancer Center, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
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 extra cranial 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. [Ann Surg Treat Res 2018;94(1):13-18] Key Words: Colorectal neoplasms, Brain, Neoplasm metastasis, Radiosurgeries, Prognosis
INTRODUCTION Colorectal cancer (CRC) is the third most common cancer, and the fourth leading cause of cancer-related deaths worldwide [15]. With advances in the diagnostic radiographic techniques and treatment of CRC, survival of patients with CRC has improved over time and the incidence of brain metastasis (BM) from CRC has gradually increased as well [2,3,5-9]. Without treatment, the prognosis of patients with BM is typically poor with median survival of 1–2 months [2,5,8,10-12]. However, with active treatments including neurosurgical resection, whole brain
Received May 13, 2017, Revised June 10, 2017, Accepted June 27, 2017 Corresponding Author: Dae-Yong Hwang Department of Surgery, Colorectal Cancer Center, Konkuk University Medical Center, Konkuk University School of Medicine, 120-1 Neungdongro, Gwangjin-gu, Seoul 05030, Korea Tel: +82-2-2030-5111, Fax: +82-2-2030-5112 E-mail:
[email protected] ORCID code: https://orcid.org/0000-0001-9082-8431
radiotherapy (WBRT), and stereotactic radiosurgery (SRS), the prognosis of these patients can be improved [3,5,7,12,13]. BM from CRC is a late stage phenomenon; therefore, the patients who have BM may be predicted to have poorer survival. The incidence rate of BM is low and the patient survival is not long; therefore, it is not frequently studied in a single center. Therefore, the purpose of this study is to analyze the clinico pathologic features and to assess the prognostic factors of BM in CRC at a single center.
Copyright ⓒ 2018, the Korean Surgical Society cc Annals of Surgical Treatment and Research is an Open Access Journal. All articles are distributed under the terms of the Creative Commons Attribution NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Annals of Surgical Treatment and Research
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Annals of Surgical Treatment and Research 2018;94(1):13-18
METHODS Patients
A retrospective analysis was made of 3,952 patients who were diagnosed with colorectal adenocarcinoma between November 2008 and December 2015. Nineteen cases were collected in 3,952 patients. The 19 patients were diagnosed with colorectal adenocarcinoma pathologically and BM by radiologic imaging. Their medical records were reviewed, including clinical charac teristics of the primary tumor and BM, neurologic symptoms, location and number of BMs, dimension of BM, Karnofsky performance status (KPS), recursive partitioning analysis (RPA), presence of extracranial metastasis, treatment modalities for BM, and survival. Metachronous metastases were defined as the diagnosis of metastases 12 months after diagnosis of the primary tumor. Treatment modalities for BM included neurosurgical resection, SRS (Gamma-knife radiosurgery), and whole brain radiotherapy (WBRT). Decision regarding treatment for BM was made by experienced neurosurgeons.
Karnofsky performance status
The Karnofsky Performance Scale (KPS) is an evaluation tool for functional impairment. This can be used to estimate the patients’ condition in order to endure the therapy and to predict the prognosis. KPS more than 70% is defined when the patient is able to carry on normal activity and to work; no special care needed [14].
Recursive partitioning analysis
RPA classification used in this study was profoundly related to the prognosis of patients with BM. Evaluation criteria were KPS, age, status of the primary tumor, and presence of extracranial metastasis. Based on these 4 criteria, patients were evaluated and classified into 3 prognostic classes. RPA class I
Table 1. Patients’ characteristics (n = 19) Characteristic Sex, male:female Age (yr) 70 60–70 Extracranial metastasis Lung Liver Peritoneal carcinomatosis Bone Systemic lymph node Vagina None Neurologic symptom Headache Ataxia Motor weakness Aphasia Nausea Mental change Memory impairment Seizure Hearing loss Asymptomatic
64 39 (0–98) 4 (21.1) 15 (78.9) 9 (47.4) 10 (52.6) 14 (73.7) 7 (36.9) 6 (31.6) 6 (31.6) 5 (26.3) 1 (5.3) 1 (5.3) 8 (42.1) 6 (31.6) 5 (26.3) 4 (21.1) 3 (15.8) 2 (10.5) 2 (10.5) 1 (5.3) 1 (5.3) 1 (5.3)
Values are presented as number, median (range), or number (%). *Interval between BM diagnosis and colorectal cancer diagnosis (months).
was 1 in 10 cases, 2 in 4 cases, and more than 3 in 5 cases. According to the RPA classification, 8 patients were classified as class II and 11 patients were classified as class III. Patients with BM received the following therapies: Four patients were treated with SRS alone, 3 patients were treated with WBRT alone, and 1 patient was treated with surgery (craniotomy and tumor removal) alone. Two patients received steroid therapy alone for pain relief without undergoing any treatment. Seven patients underwent combined therapy of surgery and SRS. Five patients received SRS after surgery for recurrent BM and 2 patients were simultaneously treated with surgery and SRS (Table 5).
Median survival after the diagnosis of BM
The median survival was 3 months after the diagnosis of BM (range, 1–10 months). The median survival of patients who received surgery plus SRS was 5 months (range, 3–10 months). SRS alone-treated patients had a median survival of 2.5 months (range, 1–5 months). WBRT alone-treated patients had a median
Table 4. Characteristics of metastatic brain tumors (n = 19) Variable
Value
Size of BM (cm) Location of BM Supratentorial Infratentorial Combination The maximal dimension of BM (cm)
