RESUMO
Medical therapy of advanced hepatocellular carcinoma (HCC) remains an emerging subject, but therapeutic sequences together with toxicity management are rarely described. Herein, we report the case of a therapeutic sequence and toxicity management in a 72-year old White male with advanced non-cirrhotic HCC. The HCC of this patient was refractory against treatment with several tyrosine kinase inhibitors, including lenvatinib and cabozantinib or immune combination of pembrolizumab and lenvatinib. Double immune combination of nivolumab and ipilimumab was effective in fourth-line treatment but resulted in immunotherapy-related grade 4 hepatitis. This toxicity responded well to high doses of corticosteroids, and reinduction of dual immune combination remained effective despite continuation of high-dose corticosteroids in a non-cirrhotic HCC. This case demonstrated the efficacy of double immune therapy in higher treatment lines in advanced non-cirrhotic HCC even if the patient was treated with other immune modulatory therapies earlier. Moreover, it can remain effective under concomitant administration of high-dose corticosteroids.
RESUMO
BACKGROUND: Brain metastases represent a severe complication in many gastrointestinal malignancies especially those arising from the upper gastrointestinal tract, including cancer of the esophagus, gastroesophageal junction, and stomach (GEC). However, there is little knowledge about the onset or potential risk factors for brain metastases (BRMs) in upper gastrointestinal cancers resulting in a lack of screening guidelines for BRMs. METHODS: We analyzed 827 patients from our cancer registry suffering from gastroesophageal cancer (GEC) and treated at the University Medical Center Göttingen between January 2013 and December 2019 for the presence of BRMs. RESULTS: From 827 patients with GEC we found 54 patients with BRMs, resulting in an incidence of 6.5%. BRMs are more frequent in male patients (90.74% vs 9.26%, p = 0.0051) and in adenocarcinomas (90.74% vs 9.26%, p = 0.0117). Mean duration for the onset of BRMs from initial cancer diagnoses was 20.9 months in limited disease (curative approach) and 9.3 months in advanced disease (palliative approach) (p = 0.0026). However, early detection of BRMs is a prognostic factor since patients with successful resection of BRMs have a better prognosis compared to those with unresectable BRMs (5.93 vs 2.07 months, p = 0.0091). CONCLUSION: In this single-center retrospective study, brain metastases (BRMs) occur with a high frequency (6.5%) in gastroesophageal cancer (GEC), significantly more often in male patients and adenocarcinomas. Since survival of these patients considerably correlates with successful BRMs resection, our observations propose further prospective trails to validate our hypothesis and ultimately the implementation of routine screening procedures to detect asymptomatic brain metastases.
