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CASE REPORT
Ahead of print publication  

Cerebellar metastasis of colon cancer at diagnosis: A very rare case


1 Department of Medical Oncology, Yozgat City Hospital, Yozgat, Turkey
2 Department of Gastroenterology, Yozgat City Hospital, Yozgat, Turkey

Date of Submission23-Apr-2020
Date of Decision08-Jun-2020
Date of Acceptance10-Sep-2020
Date of Web Publication03-Nov-2021

Correspondence Address:
Melih Simsek,
Department of Medical Oncology, Yozgat City Hospital, Yozgat
Turkey
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_514_20

 > Abstract 


Colorectal cancer (CRC) is one of the leading causes of cancer deaths worldwide. Besides, brain metastasis from CRC is relatively rare. A 68-year-old male referred to the emergency clinic with headache, vertigo, nausea, and vomiting. A cerebellar mass lesion was determined and totally excised. Pathology revealed a metastatic adenocarcinoma. Colonoscopic biopsy obtained from the lesion in the colon was reported as adenocarcinoma. A cerebellar recurrent lesion occurred, and radiotherapy was initiated. After radiotherapy, FOLFOX-bevacizumab combination regimen was initiated as the first-line treatment of the patient with metastatic colon cancer. Significant improvements in the clinical outcomes of CRC were achieved in recent years. However, brain metastasis from CRC has a poor prognosis. We aimed to report a rare presentation of CRC with synchronous brain metastasis.

Keywords: Adenocarcinoma, cerebellar metastasis, colon cancer, radiotherapy, surgery



How to cite this URL:
Simsek M, Deveci M. Cerebellar metastasis of colon cancer at diagnosis: A very rare case. J Can Res Ther [Epub ahead of print] [cited 2021 Dec 5]. Available from: https://www.cancerjournal.net/preprintarticle.asp?id=329852




 > Introduction Top


Colorectal cancer (CRC) is a common cancer.[1] It is particularly seen in older patients.[2],[3] 5-year overall survival (OS) rate decreases with advancing stage.[1] About 20% of the patients has metastasis at the diagnosis.[1] Brain metastasis is relatively rare with an incidence of 0.6%–3.2%.[4] Synchronous brain metastasis in CRC patients is less frequent.[5] Despite advances in the treatment and OS reaching 40 months,[6] the prognosis is poor for metastatic patients.[7] Median progression-free survival has been reported as 8–11 months.[8],[9] However, median OS after the diagnosis of brain metastasis has been reported as 6–9 months.[5] We aimed to report a metastatic colon cancer diagnosed with synchronous cerebellar metastasis.


 > Case Report Top


A 68-year-old male referred to an emergency clinic of another health-care center with headache, vertigo, nausea, and vomiting in January 2020. A computerized tomography scan showed a mass lesion in the right cerebellum. After this finding, the patient was transferred to our center. The magnetic resonance imaging of the brain showed an isointense signal feature on precontrast T1-weighted axial image in the right paramedian cerebellary dentate nucleus and heterogenous hypointense on 3D T2-weighted images at the same location. The lesion has periferic, irregular vasogenic edema on fluid-attenuated inversion recovery sequences. The lesion shows mostly periferic, heterogeneous contrast enhancement following intravenous gadolinium administration on postcontrast 3D T1 images [Figure 1] and [Figure 2]. The pathological assessment of the totally excised lesion revealed a metastatic adenocarcinoma with unknown origin. A detailed systemic examination was planned to determine the primary of this malign tumor. A primary descending colonic lesion and multiple liver metastases were determined with computerized tomography of the thorax and abdomen. There were multiple hypodense mass lesions with peripheral contrast enhancements. A diagnostic colonoscopy was performed and revealed a fragile mass lesion nearly obliterating the lumen in the middle section of the descending colon [Figure 3]. Pathological evaluation of the colon lesion was reported as adenocarcinoma [Figure 4]a and [Figure 4]b. Genetical analysis for extended rat sarcoma (RAS), murine sarcoma viral (v-raf) oncogene homolog B1 (BRAF), and microsatellite instability (MSI) was ordered. Unfortunately, a recurrent lesion occurred in the operated cerebellar region and palliative radiotherapy was initiated. The genetical analysis report revealed microsatellite stable, BRAF, and KRAS wild type, and NRAS mutant tumor. With all these data, FOLFOX-bevacizumab combination regimen was initiated as the first-line treatment of the patient with metastatic colon cancer.
Figure 1: Isointense signal feature on precontrast T1-weighted axial image in right paramedian cerebellar dentate nucleus

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Figure 2: Heterogenous hypointense signal feature on 3D T2-weighted image in right paramedian cerebellar dentate nucleus. The lesion has peripheral, irregular vasogenic edema on fluid-attenuated inversion recovery sequences and shows heterogeneous contrast enhancement

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Figure 3: Colonoscopic vision of colon adenocarcinoma

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Figures 4: (a and b) Light microscopic images of colon adenocarcinoma (a: H and E ×40) (b: H and E ×40)

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 > Discussion Top


Although its incidence is decreasing, CRC is still one of the leading causes of cancer deaths worldwide.[1] Stage of disease is the most important prognostic factor and OS rates decreases with advancing stage.[1] It has been reported that more than 20% of CRC cases have been diagnosed with metastatic stage.[1] CRC can metastasize to any organ, including bone, brain and distant lymph nodes, while the liver, lung, and peritoneum being the most common sites. Although brain metastasis from CRC is a very rare clinical scenario, it is a lethal event and there is an urgent need to find effective treatment options.[10]

A research of the literature showed that generally the studies have focused on brain metastasis occurred during the course of CRC. Synchronous brain metastasis of CRC was reported to be a rare and late phenomenon.[4] Most of these cases have been determined as metachronous metastasis[4] and synchronous disease has been reported less frequent.[5] We did not find a special underlyning of cerebellar metastasis for these synchronous brain metastasis patients. Interestingly, our patient was diagnosed with synchronous cerebellar metastasis of colon cancer.

The median age at the diagnosis of brain metastasis in CRC patients has been reported to be ranged from 56 to 73 years.[2] Similar to the literature, our patient was 68 years old at the diagnosis of brain metastasis from colon cancer.

Because brain metastasis from CRC is a rare clinical event, the optimal treatment modality is still controversial. Surgery is the preferred first treatment option, especially for solitary metastasis, and may have survival benefit. However, in our case, an early recurrence in first metastasectomy site has occurred while systemic treatment has been planning in our patient. Following identification of this early recurrence, whole brain radiotherapy was initiated.

In summary, significant improvements in the clinical outcomes of CRC have been achieved in recent years, and the major role belongs to systemic therapies including targeted therapies and immunooncology agents. Genetical analysis, including KRAS, NRAS, BRAF, and MSI, has predictive and prognostic roles, and they are guides for treatment approaches. However, brain metastasis from CRC has a poor prognosis, and there is still an urgent need for effective therapies. With this case, we aimed to report a rare presentation of CRC as synchronous cerebellar metastasis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Miller KD, Fidler-Benaoudia M, Keegan TH, Hipp HS, Jemal A, Siegel RL. Cancer statistics for adolescents and young adults, 2020. CA Cancer J Clin 2020:1-17.  Back to cited text no. 1
    
2.
Pallis AG, Papamichael D, Audisio R, Peeters M, Folprecht G, Lacombe D, et al. EORTC elderly task force experts' opinion for the treatment of colon cancer in older patients. Cancer Treat Rev 2010;3683-90.  Back to cited text no. 2
    
3.
Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018 GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68394-424.  Back to cited text no. 3
    
4.
Christensen TD, Spindler KL, Palshof JA, Nielsen DL. Systematic review Brain metastases from colorectal cancer–Incidence and patient characteristics. BMC Cancer 2016;16260.  Back to cited text no. 4
    
5.
Lu X, Cai Y, Xia L, Ju H, Zhao X. Treatment modalities and relative survival in patients with brain metastasis from colorectal cancer. Biosci Trends 2019;13182-8.  Back to cited text no. 5
    
6.
Wang Y, Liu S, Liu S, Li X, Liu Q, Zou X, et al. Regorafenib treatment for management of colorectal cancer A systematic review and meta-analysis of 6 randomized controlled trials. Am J Ther 2018;25e276-8.  Back to cited text no. 6
    
7.
Gustavsson B, Carlsson G, Machover D, Petrelli N, Roth A, Schmoll HJ, et al. A review of the evolution of systemic chemotherapy in the management of colorectal cancer. Clin Colorectal Cancer 2015;141-10.  Back to cited text no. 7
    
8.
Venook AP, Niedzwiecki D, Lenz HJ, Innocenti F, Fruth B, Meyerhardt JA, et al. Effect of first-line chemotherapy combined with cetuximab or bevacizumab on overall survival in patients with KRAS wild-type advanced or metastatic colorectal cancer A randomized clinical trial. JAMA 2017;3172392-401.  Back to cited text no. 8
    
9.
Kopetz S, Grothey A, Yaeger R, Van Cutsem E, Desai J, Yoshino T, et al. Encorafenib, binimetinib, and cetuximab in BRAF V600E-mutated colorectal cancer. N Engl J Med 2019;3811632-43.  Back to cited text no. 9
    
10.
Kruser TJ, Chao ST, Elson P, Barnett GH, Vogelbaum MA, Angelov L, et al. Multidisciplinary management of colorectal brain metastases A retrospective study. Cancer 2008;113158-65.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

 
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