isolated brain metastasis – a rare site of recurrence …...1. pietzner as, oskay et, et al. brain...
TRANSCRIPT
i n t e r n a t i o n a l j o u r n a l o f e p i l e p s y 2 ( 2 0 1 5 ) 8 7 – 8 9
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: http://www.journals.elsevier.com/international-journal-of-epilepsy
Case Report
[6_TD$DIFF]Isolated brain metastasis – A rare site of recurrence
in a recurrent epithelial carcinoma ovaryVineet Talwar a, Chandragouda Dodagoudar a, Sajjan Rajpurohit a,Shubhra Raina a,*, Jyoti Talwar c, Deepika Chauhan b
aDepartment of Medical [7_TD$DIFF]Oncology, Rajiv Gandhi Cancer Institute and Research [8_TD$DIFF]Centre, Delhi, IndiabRajiv Gandhi Cancer Institute and Research [10_TD$DIFF]Centre, Delhi, IndiacSRHCH, Delhi, India
a r t i c l e i n f o
Article history:
Received 16 September 2015
Accepted 18 September 2015
Available online 29 October 2015
Keywords:
Carcinoma ovary
[17_TD$DIFF]Epithelial carcinoma
[18_TD$DIFF]Multiple line of treatment
[19_TD$DIFF]Recurrence
Brain metastasis
a b s t r a c t
A [15_TD$DIFF]40-year-old lady presented with 15 months after completion of adjuvant chemotherapy
with headache and impaired memory. [16_TD$DIFF]MRI brain revealed isolated frontal lobe metastasis.
She underwent surgical excision, whole brain RT followed by six cycles of chemotherapy.
# 2015 Indian Epilepsy Society. Published by Elsevier B.V. All rights reserved.
1. Introduction
[20_TD$DIFF]Central nervous system involvement in epithelial ovariancancer (EOC) occurs only in 0.49–2.2% of patients and isassociated with a poor prognosis. Till now no significant riskfactors have been identified and currently there are notreatment guidelines. The options of treatment for EOC withbrain metastases include surgery, Radiation, systemic and/orintrathecal chemotherapy, or a combination regime.We reporta patient of epithelial carcinoma ovary who had recurrence inform of isolated brain metastasis following which she was
* Corresponding author [12_TD$DIFF]at: Department of Medical Oncology, Rajiv GanIndia. Tel.: +91 01147022262.
E-mail addresses: [email protected] (V. Talwar), drchand(S. Rajpurohit), [email protected] (S. Raina), drjyotitalwar@yahttp://dx.doi.org/10.1016/j.ijep.2015.09.0022213-6320/# 2015 Indian Epilepsy Society. Published by Elsevier B.V.
treated with combination chemotherapy and she is on followup since 2 years.
2. Case [21_TD$DIFF]summary
A 39-year-old lady nondiabetic, nonhypertensive a case ofadvanced carcinoma ovary [22_TD$DIFF](High grade serous) with initial CA125 of 5170 [23_TD$DIFF]U/ml. She was treated with 4 cycles of neoadjuvantchemotherapy with paclitaxel 300 mg and carboplatin 600 mgfollowed by interval cytoreductive surgery. The histopatholog-ical examination revealed residual disease. She was given
dhi Cancer Institute and Research Centre, Rohini, Sector 5, [13_TD$DIFF]Delhi,
[email protected] (C. Dodagoudar), [email protected] (J. Talwar), [email protected] (D. Chauhan).
All rights reserved.
[(Fig._1)TD$FIG]
Fig. 1 – MRI brain postoperative state showing a lesion inthe left basal ganglia region.
i n t e r n a t i o n a l j o u rn a l o f e p i l e p s y 2 ( 2 0 1 5 ) 8 7 – 8 988
2 more cycles of adjuvant chemotherapy. [24_TD$DIFF]She was kept onregular followup. Her serial CA 125 levels done every 3monthlywere within normal limits. After about 15 months of her lastchemotherapy, shecomplainedofheadache, irrelevant talk and
[(Fig._2)TD$FIG]Fig. 2 – [1_TD$DIFF](A) Metastatic deposits of serous carcinoma infiltrating ththe meninges [3_TD$DIFF][H&E; T100]. (C) Immunopositivity for CK7 [4_TD$DIFF][DAB; T
impaired memory and absence seizures. MRI brain revealedlarge cystic and solid enhancing mass in left frontal regioninvolving gangliothalamic region (Fig. 1). The Whole body PETCT did not show any evidence of disease outside the brain.Ophthalmological examination revealed grade II papilloedema.She underwent surgical excision of the [25_TD$DIFF]tumor. The histopatho-logical examination was suggestive of high grade serouscarcinoma consistent with metastasis in a known case ofcarcinoma ovary. On Immunohistochemistry [25_TD$DIFF]tumor cellsexpress CK7 and WT-1. [26_TD$DIFF]She was BRCA negative (Fig. 2a,b,c,d).
The case was discussed in a [25_TD$DIFF]tumor board and was advisedWhole brain radiotherapy followed by chemotherapy. Shewastreated with WBRT 30 Gy/15# followed by 6 cycles of palliativepaclitaxel and carboplatin chemotherapy. Post 6 cycle reeval-uation did not show any evidence of disease. She is now onregular follow up since 2 years.
3. Discussion
The CNSmetastasis is commonly seen in solid [27_TD$DIFF]tumors such aslung cancer, breast cancer and malignant melanoma and isvery rare in EOC. The various studies have suggested anincidence between 0.49%and 2.2% and ameta-analysis reportsan average incidence of brain metastases to be 1.01%. Variousauthors have suggested that patients with advanced disease(FIGO III and IV) and/or poor tumor differentiation (grade3 disease) are at higher risk for developing brain metastases.
e brain parenchyma [2_TD$DIFF][H&E; T100]. (B) Tumor infiltration into100]. (D) Nuclear immunopositivity for WT-1 [5_TD$DIFF][DAB; T100].
i n t e rn a t i o n a l j o u rn a l o f e p i l e p s y 2 ( 2 0 1 5 ) 8 7 – 8 9 89
Brain metastases, either single or multiple, occur after amedian time of 21.5 months (range [28_TD$DIFF]0–126 months) followingthe initial diagnosis of EOC. In the majority of the casesmultiple lesions are found. Forty to sixty percent of the casesshow disseminated recurrent disease, with the remainingcases showing the brain to be the only metastatic site.Generally, the prognosis of EOC patients and brain metastasisis very heterogeneous. Currently, no standard treatmentguidelines are available for EOC patients with brain metasta-ses and must be individualized. Patients receiving onlysymptomatic treatments have a median survival of 2 months(range [29_TD$DIFF]0–15months) while tumor targeting therapy, regardlessof the modality employed, seems to improve median survival.According to Pectasides [30_TD$DIFF]et al.,3 treatment including surgery,radiotherapy [31_TD$DIFF]� chemotherapy shows advantages over otherforms of treatmentwith amedian survival of 20months (range1–57+ months) and 21.8 months (range 1–120+ months)respectively. This possible bias can be excluded only byconducting a prospective randomized study. Surgical resectionis considered the best therapeutic approach and can beperformed alone or in combination with chemotherapy andradiotherapy depending on the general condition of thepatient and the specific tumor pattern[32_TD$DIFF].1,2 The role ofchemotherapy in the treatment of brain metastases remainscontroversial.
Patientswhohavenewneurological symptoms in recurrentovarian cancer, the presence of brain metastasis must beexcluded. EOC patients with brain metastases should receivemultidisciplinary treatment [33_TD$DIFF].1,2 Randomized trials by interna-tional collaborative groups are warranted to define the realprevalence of brain metastasis and to define best therapeuticapproach in this palliative setting.
[34_TD$DIFF]Conflicts of interest
All authors have none to declare.
r e f e r e n c e s
1. Pietzner as, Oskay et, et al. Brain metastasis from Epithelialovarian cancer – overview and optimal management.Anticancer Res. 2009;29:2793–2798.
2. Choo Bok AkA, Walji wz, et al. Prolonged relapse free survivalin two patients with isolated brain metastasis from epithelialovarian cancer. J Clin Oncol. 2010;28:e271–e272.
3. Pectasides D, Pectasides M, Economopoulos T. Brainmetastases from epithelial ovarian cancer: a review of theliterature. Oncologist. 2006;11:252–260.