The most important feature of what we often call an advanced tumor, usually staged as stage IV, is the occurrence of distant metastases. Distant metastases from esophageal cancer most often occur in the lungs, liver, or bone, but there are specific patients who are more likely to have brain metastases.
In this article, we will use one patient’s story to understand the development of a treatment plan for brain metastases from esophageal cancer.
Mr. Xia is 46 years old, and since September 2015, he has felt a choking sensation when eating, swallowing rice or steamed buns with more effort than before, and sometimes needing a sip or two of water or congee to swallow.
First treatment
After gastroscopy, pathological biopsy, and imaging, Mr. Xia was diagnosed with lower esophageal cancer, clinical stage IIIA, with metastasis to the cardia lymph nodes, but no distant metastasis.
The doctor recommended 4 cycles of etoposide + cisplatin “neoadjuvant chemotherapy” to shrink the mass and facilitate surgical resection.
But after chemotherapy, the thoracic surgeon found that the mass was still difficult to remove. After a multidisciplinary consultation, the doctors recommended radical radiotherapy for Mr. Xia.
The doctors chose the intensity-modulated conformal radiotherapy (IMRT) technique, which irradiates the esophageal lesion and metastatic lymph node area; the dose is 60Gy (“gorey” in Chinese) / 28F, that is, a total dose of 60Gy in 28 fractions.
After starting treatment, Mr. Xia developed symptoms such as painful swallowing and leukopenia. The doctor prescribed mucosal protective agents and leukocyte-raising drugs for him, and the adverse effects slowly subsided. One month after the end of radiotherapy, these symptoms disappeared completely. He came to the hospital for an efficacy evaluation as prescribed by the doctor, which showed that the lesion had achieved partial response (PR). Since then, he has been reviewed every 3 months and his condition is stable.
Recurring disease, brain metastases detected
In October 2016, Mr. Xia developed symptoms such as poor writing and unsteady walking in his right hand. He immediately came to the hospital and had a cranial MRI and other tests, which revealed multiple brain metastases in the bilateral frontoparietal lobes and cerebellum, with no progression of the primary esophageal foci.
Seeing this result, Mr. Xia was very desperate. The doctor gave him psychological guidance: although brain metastases appeared, timely and effective treatment can reduce or even disappear neurological symptoms, without affecting normal life, and a considerable survival period can be obtained. After hearing the doctor’s words, Mr. Xia rekindled his fighting spirit against the tumor.
Second treatment
Mr. Xia had more brain metastases that could not all be removed at once. And there is a blood-brain barrier between brain cells and blood vessels that can prevent chemotherapy drugs from entering the brain. Therefore, doctors do not recommend surgery and chemotherapy and may try radiation therapy.
Radiotherapy for brain metastases can be whole-brain radiotherapy and stereotactic radiotherapy. Whole-brain radiotherapy can irradiate all metastases at once and has relatively few side effects, which is appropriate for Mr. Xia’s case.
October 13, 2016, was the first day that Mr. Xia received whole-brain radiotherapy at a dose of 30Gy/10F.
On day 3 of treatment, he suddenly developed twitching and dizziness in his right limb, which improved on its own after 2 minutes. He wondered why his symptoms were getting worse after starting treatment. Was the treatment wrong?
The doctor said:
At the beginning of radiation therapy, the brain is irradiated with radiation, which causes transient brain tissue edema, resulting in increased intracranial pressure, causing temporary exacerbation of neurological symptoms and even symptoms such as epilepsy. By the time the course of treatment is half over, the brain edema gradually subsides and the symptoms will gradually decrease.
After hearing the doctor’s explanation, the stone fell from Mr. Xia’s heart. After six sessions of radiation therapy, he felt much better about writing and walking, his balance was restored, and he had no more seizures.
By the end of radiation therapy, his neurological symptoms had largely disappeared, and a repeat cranial MRI 1 month later showed that the brain metastases had shrunk significantly. The doctor told Mr. Xia to rest and take care of his nutrition, and to review his condition every 3 months and to visit the hospital if he was unwell.
In March 2017, Mr. Xia was seen again, and his condition was stable and his quality of life was good.
Summary
The incidence of brain metastases from esophageal cancer is extremely low, at about 3%. Studies have shown that poorly differentiated, late-staged thoracic esophageal cancer is prone to brain metastases.
The first symptoms of brain metastases are fatigue, headache, and seizures. Head MRI is the first choice for diagnosis. Treatment consists of surgery, radiation therapy, and chemotherapy.
1. Surgery is indicated for patients with ≤3 brain metastases that are easily resected at the site. However, regardless of the number and size of metastases, as long as life-threatening complications such as tumor stroke and obstructive hydrocephalus occur, surgical decompression should be performed to ensure life safety.
2. Radiotherapy is an effective treatment for brain metastases. Whole-brain radiotherapy is mainly used for the initial treatment of metastases>3 and for adjuvant treatment after intracranial surgery; stereotactic radiotherapy is mainly used for patients with brain metastases less than 3-4 cm in diameter and less than 3-4 in number.
3. Chemotherapy is often used in combination with other treatments, the most common drug being temozolomide.
Brain metastases from esophageal cancer have a survival time of less than 1 month in half of patients without intervention. However, with early detection and individualized comprehensive treatment, survival can be extended to 9-10 months and quality of life can be improved.
Disclaimer:
Tumor disease and treatment options are extremely complex and treatment should be fully individualized, and this case does not represent a treatment decision for a “similar patient. Please seek professional advice from a competent physician regarding your specific treatment plan.
Co-Author: Dr. Yangzi Zhang, Peking University Cancer Hospital