Downloaded from http://journals.lww.com/amjclinicaloncology by BhDMf5ePHKbH4TTImqenVPWx2hcEpdL/5a04VBAMd2Gacs+qVlci52gr+Xkv6kHn on 05/26/2020 Brain Metastases From Gynecologic Malignancies Prevalence and Management Dimitrios Nasioudis, MD,* Anitra Persaud, BA,† Neil K. Taunk, MD,‡ and Nawar A. Latif, MD, MSCE, MPH* Objective: The objective of this study was to investigate the preva- lence, clinicopathologic characteristics, management, and outcomes of patients with brain metastasis (BM) from gynecologic malignancies in a large hospital-based database. Materials and Methods: The National Cancer Database (NCDB) was accessed and patients with ovarian, uterine, or cervical cancer and BM were identified. We identified those who received radiation therapy (RT) as whole-brain radiation therapy (WBRT) or stereotactic radio- surgery (SRS). Kaplan-Meier curves were generated to determine median overall survival (OS) and compared with the log-rank test. Results: A total of 853 patients with BM were identified. The rate of BMs upon diagnosis was 0.4% (211/57,160) for patients with cervical cancer, 0.2% (498/243,785) for patients with uterine, and 0.2% (144/92,301) for ovarian malignancies. Only 30.4% had isolated BM, while 52.2% had lung metastasis. Approximately half of the patients (50.1%) received chemo- therapy, while brain RT was administered to 324 (38%) patients. Among patients who received brain RT, only 60 (18.5%) had SRS, while 264 (81.5%) had WBRT. Patients who underwent SRS had a better survival (n = 47, median OS = 9 mo) than those who received WBRT (n = 201, median OS = 4.73 mo, P = 0.018), or those who did not receive any brain RT (n = 370, median OS = 4.01 mo, P = 0.007). Conclusions: The incidence of BM among patients with gynecologic malignancies is rare and associated with poor survival. For select patients, SRS may be associated with prolonged survival. Key Words: brain metastases, ovarian cancer, cervical cancer, radiation therapy (Am J Clin Oncol 2020;43:418–421) B rain metastases (BMs) are rare among patients with gyne- cologic malignancies with incidence rates of 0.4% to 1.2%, 0.3% to 2.2%, and 0.3% to 0.9% in endometrial, ovarian, and cervical cancers, respectively. 1–3 The presence of metastatic brain lesions from gynecologic cancers are generally indicative of poor prognosis. 1–6 The development of multimodal therapies as well as advancements in surgical techniques, imaging, and radiation therapy (RT) have increased the therapeutic opportunity for patients with BM. The rise in the incidence of BM from ovarian and uterine cancers has been attributed to the increased lifespan of these patients such that there is an opportunity for BM to develop, and advanced imaging modalities to better identify those with BM. 1,4,7 Novel treatment options such as stereotactic radiosurgery (SRS) may be associated with prolonged survival of patients with BM. 8 However, factors influencing a patient’s candidacy for these new treatment modalities should be assessed to ensure properly tailored clinical management plans. Given the rarity of BM from gynecologic cancers, there is a paucity of research regarding the outcomes and prognostic factors in this area. Further, agreement on therapeutic guide- lines has not been established. The present study aimed to investigate the epidemiology, management, and outcomes of patients with gynecologic malignancies with BM using a large hospital-based multi-institutional database. MATERIALS AND METHODS Patients diagnosed between 2010 and 2015 with a pathologically confirmed primary invasive tumor of the uterus, cervix, or ovary were selected from the National Cancer Database (NCDB). The NCDB established jointly by the American Cancer Society and Commission on Cancer of the American College of Surgeons, is a hospital-based database capturing ∼70% of all malignancies diagnosed in the United States. Patient data are prospectively collected from partic- ipating commission-accredited cancer programs and are frequently audited to ensure their high quality. All data are deidentified and available for research purposes. The American College of Sur- geons and the Commission on Cancer have not verified and are not responsible for the analytical or statistical methodology employed, or the conclusions drawn from these data. The present study was deemed exempt from Institutional Board Review from Penn Medicine. On the basis of the collaborative staging fields, patients diagnosed with BM upon presentation were selected for further analysis. Demographic, clinicopathologic, and treatment varia- bles were extracted from the deidentified NCDB dataset. Patient race was recoded into white, black, and other/unknown, insurance status into private, government (including Medicaid and Medicare), and uninsured/unknown, and age was grouped into r65 and > 65 years. The presence of comorbidities was assessed from the Charlson-Deyo Comorbidity Index and categorized as present (score > 0) or absent (score 0). Patients who received whole-brain radiation therapy (WBRT) or SRS were identified. SRS was delivered by a linear accelerator or GammaKnife Radiosurgery (GKRS). Overall survival (OS) was defined as months elapsed from tumor diagnosis to the date of death or last follow-up. To avoid immortal time bias, only patients with at least 1 month of fol- low-up were included in the survival analysis. Kaplan-Meier curves were generated to determine the median OS while uni- variate analysis was performed with the log-rank test. A From the *Division of Gynecologic Oncology; ‡Department of Radiation Oncology, University of Pennsylvania Health System; and †Perelman School of Medicine, Philadelphia, PA. The authors declare no conflicts of interest. Reprints: Dimitrios Nasioudis, MD, Department of Obstetrics and Gyne- cology, Division of Gynecologic Oncology, Hospital of the University of Pennsylvania, Helen O. Dickens Center for Women’s Health, 3400 Spruce Street, 1 West Gates, Philadelphia, PA 19104. E-mails: dimitrios.nasioudis@uphs.upenn.edu; dnasioudis@gmail.com. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0277-3732/20/4306-0418 DOI: 10.1097/COC.0000000000000689 ORIGINAL ARTICLE 418 | www.amjclinicaloncology.com American Journal of Clinical Oncology  Volume 43, Number 6, June 2020 Copyright r 2020 Wolters Kluwer Health, Inc. All rights reserved.