Short SurveyBrain metastases of epithelial ovarian carcinoma responding to cisplatin and gemcitabine combination chemotherapy: a case report and review of the literature
Introduction
Epithelial ovarian carcinoma (EOC) represents the leading cause of mortality for gynecologic cancer in the United States and many Western nations [1]. Despite aggressive surgery and chemotherapy, most patients with advanced disease will ultimately relapse and die of the disease. On the other hand, the survival of EOC patients has improved substantially over the recent decades. Combination of surgical cytoreduction followed by cisplatin or carboplatin with paclitaxel now represents the standard front line regimen for patients with advanced disease after demonstration of superior survival in randomized clinical trials [2].
The marked prolongation of survival resulting from the multimodality treatment is revealing the natural history of EOC. More patients live long enough to develop distant metastases. Among sites of distant relapse, brain metastases, once considered very rare, are now being diagnosed with an increasing frequency [3]. Back in 1983, Budd et al. [4] have observed three cases of brain metastases among 42 stage III, IV or recurrent EOC patients treated by combination of cisplatin, doxorubicin and cyclophosphamide. Two of the patients with brain metastases had earlier a surgically confirmed complete response in the abdomen. Menczer et al. [5] observed brain metastases in 3 out of 17 patients after negative second-look laparotomy previously treated by intraperitoneal chemotherapy. After the introduction of paclitaxel in 1990s, cases of brain metastases in patients with abdominal disease responding to paclitaxel have been observed [6]. The blood–brain barrier significantly limits the penetration of both paclitaxel and platinum compounds, although clinically relevant drug concentrations were observed in macroscopic brain tumors [7], [8], [9].
We report here on a case of brain metastases developing in a patient with recurrent EOC after complete response to platinum/paclitaxel chemotherapy. The brain metastases have responded to a multimodality regimen including surgery, radiation and chemotherapy by combination of cisplatin, gemcitabine and 5-fluorouracil. As all reports on EOC brain metastases are either case reports or small retrospective series, a pooled analysis of the published reports was performed to identify the factors associated with treatment outcome.
Section snippets
Case report
A 39-year-old woman with stage I (T1cN0M0) grade 2 papillary serous cystadenocarcinoma of the ovary was treated by bilateral salpingo-oophorectomy, hysterectomy and omentectomy in November 1995 (Table 1). The surgical staging in this patient was, however, incomplete as no lymphadenectomy was performed. In February 1999, the patient presented with enlarged right inguinal lymph nodes and pelvic recurrence that was treated by pelvic radiation (in an outside hospital) (Fig. 1).
In May 1999, the
Material and methods
Because of limited information on the outcome of EOC brain metastases in case series, we performed a pooled analysis of the published reports in patients with EOC brain metastases. Reports on EOC brain metastases were identified through searching the MEDLINE database and reference lists of publications. Table 2 identifies hospital-based series of patients with EOC central nervous system (CNS) metastases. Data for the pooled analysis were extracted only from those reports that contained
Results
The survival after treatment in EOC patients with brain metastases treated by different therapeutic modalities is summarized in Table 4. It is evident that the most favorable outcome was observed in patients treated by surgery combined with radiotherapy and/or chemotherapy. The survival of patients treated by all three modalities was not significantly better than survival of patients treated by radiotherapy combined either with surgery or chemotherapy. The survival of the few patients treated
Analysis of the published literature
CNS metastases in patients with EOC are rare. Based on hospital population-based series, the estimates of the frequency of CNS metastases in EOC range between 0.5% and 12%. EOC represents an unusual primary among the patients with central nervous system metastases. In large series of patients with brain metastases, 6 out of 916 (0.7%) [15], or 13 out of 740 patients (1.8%) [16] had EOC. The characteristics of hospital population-based series of EOC patients with CNS are shown in Table 2. The
Acknowledgements
The present work was supported, in part, by the grant of Ministry of Education of the Czech Republic CEZ-MŠMT 115000021.
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