458
Surg Neurol 1991 ;36 :458-61
Solitary Cerebral Metastasis from Lung Cancer with Very Long Survival : Report of Two Cases and Review of the Literature Maurizio Salvati, M .D., Marco Artico, M .D., Simona Carloia, M .D., Epimenio Ramundo Orlando, M .D., and Franco Maria Gagliardi, M.D. Department of Neurological Sciences, Department of Neurosurgery, and Second Service of Neuroradiology, "La Sapienza" University of Rome, Rome, Italy
Salvari M, Artico M, Carloia S, Orlando ER, Gagliardi FM . Solitary cerebral metastasis from lung cancer with very long survival: report of two cases and review of the literature . Surg Neurol 1991 ;36 :458-61 .
Solitary cerebral metastases from lung cancer are not uncommon clinical events . Whatever treatment is adopted, long-term survival is rare . Very rare indeed are reports of patients surviving the discovery of lung cancer and brain metastasis for 10 years or more . Indeed, only 16 cases have been reported to our knowledge . We report two further cases, stressing the importance of correct clinicopathological staging so that treatment may be conducted in the way most likely to ensure longer and better survival and, pending a therapeutic breakthrough, to increase the number of long-term survivors . Brain metastasis ; Lung neoplasm ; Radiotherapy ; Surgery ; Chemotherapy KEY WORDS :
The brain is one of the most common sites of metastases from solid tumors of the lung and mammary gland [3,10,22,29,33] . Anywhere from 15% to 80% of lung cancers metastasize to the brain, depending on the type of series, clinical or postmortem, with a mean of about one third of all patients having a non-small-cell carcinoma of the lung [7,11,14,15,19,24] . The brain lesion is solitary, at least on first diagnosis, in 30% to 50% of cases [7,19,24}, and these are the cases most likely to respond to surgical treatment . Nonetheless, although the mean survival (for nonsmall-cell lung cancer) after surgery plus radiotherapy is decidedly longer than after radiotherapy alone, namely, 26 months versus 14 months [15] or 19 months versus 9 [20], long-term survival is rare [1,2,8,9,12,14,1619,21,23-26,31) . Address reprint requests to: Maurizio Salvati, M .D ., Via Cardinal Agliardi 15, 00165 Rome, Italy . Received February 14, 1991 ; accepted April 29, 1991 . 0 1991
by Elsevier Science Publishing Co., Inc.
We report two cases of long-term survivors after the diagnosis of adenocarcinoma of the lung and brain metastases .
Case Reports Case I A 62-year-old man gave a 15-day history of two episodes of generalized epileptic seizures . He had undergone surgery 2 months before for the removal of an adenocarcinoma of the superior lobe of the left lung . Neurological examination was normal . A computed tomography (CT) brain scan imaged a hyperdense spaceoccupying lesion in the right frontal lobe, which was enhanced on contrast injection . Perilesional edema was present (Figure 1). Surgery accomplished total removal of a grayish-red tumor, which was not on the surface and which proved on histological examination to be a metastatic adenocarcinema (Figure 2) . The postoperative course was uneventful and the patient was discharged free from neurological deficits on day 8 . He then received a course of radiotherapy (40 Gy whole brain) in addition to regional radiotherapy (60 Gy) and monochemotherapy (intravenous cyclophosphamide) for complementary treatment of the lung cancer . The patient was followed up for 11 years with numerous diagnostic procedures (including brain and total body CT scans) and showed no signs of resumption of the disease . In 1991, diffuse osseous pain and a slight dyspnea appeared. The radiodiagnostic exams showed diffuse bone metastases and relapse of lung carcinoma . Only palliative therapy was carried out and the patient died after 3 months . No autopsy was permitted .
Case 2 A 55-year-old man came to our observation in 1965 with a 2 week history of headache, vomiting (even on an empty stomach), and slowed mentation . Neurological 0090-3019191/53 .50
Long-Term Survival from Cerebral Metastasis
Surg Neurol 1991 ;36 :458-61
4 59
walnut-sized, apparently well-circumscribed lesion was found in the right occipital lobe . The removal was total from the gross point of view . Histological examination revealed a typical picture of a metastatic adenocarcinoma (Figure 3) . The postoperative course was uneventful and the patient was discharged 8 days later . Radiotherapy was given to the whole brain (45 Gy) . An oncologic screening was also performed and 20 days later an x-ray exam of the thorax confirmed by CT showed a round lesion in the left pulmonary upper lobe . The patient underwent thoracic surgery in another institution and a left pneumonectomy was done . Histological examination revealed an adenocarcinoma of the lung . Regional radiotherapy (60 Gy) was administered to the patient, who survived illness free for 10 years . He died in 1975 from multiple lung and bone recurrences of the malignancy . There was no autopsy .
Discussion
Figure 1.
Case 1 . Craniocerebral CT scan showing a right frontal mass with a perilerional edema enhanced by intravenous contrast medium .
examination revealed bilateral papilledema and a left homonymous hemianopia . Plain x-rays showed the skull to be normal and a cerebral angiography disclosed a tumor blush in the right occipital lobe . The patient was operated on and at surgery a reddish,
Solitary brain metastases do not usually spell long-term survival, and lesions arising from the lung are no exception [3,10,19,20,27-29] . Instances of 5-year survival are rarely reported, with only 34 cases having been published [1,2,8,9,12,16-19,21,23-26,31} and, of these, only 16 were reported free of disease after 10 years or more [2,7,14,17,19,23-25] . Among the 10-year survivors described in detail, males predominate in the ratio of 8 : 1 ; no patient had small-cell carcinoma. The histotypes were adenocarcinoma in six cases, squamous carcinoma in four, and large-cell carcinoma in one . The predominance of males seems to depend on the higher incidence of lung cancers among males, while the absence of small-cell tumors is in keeping with the de-
Figure
2. Care L Histological picture showing a typical adenocarcinomatous area . Cells of various aspects and sizes are visible . Mitosis is recognizable (hematoxvlin and eosin stain x200) .
460
Surg Neurol 1991 ;36 : 4 5 8-61
Salvati et al
Figure 3 . Case 2 . Histologic specimen showing an evident cellular polymorphism and various mitoses, also atypical. The adenocarcinomatous pattern is easily recognizable (hematoxylin and eosin slain X100) .
cidedly poorer prognosis of this histotype than for other lung cancers . The relative preponderance of adenocarcinomas over other histotypes is confirmed by several "general" series, although in some series they are equal in frequency to squamous or large-cell carcinomas [7,14,22,33] . Tomlinson et al [321 adduce in support of this the fact that brain metastases are more often present when the primary tumor affects the peripheral regions of the pulmonary parenchyma, often the site of adenocarcinomatous tumors . In our two cases the patients were males and the histotype was adenocarcinoma. The primary tumor in "long-term survivors" seems to prefer the superior lobe of the left lung and the intracranial metastasis tends to gravitate to the sylvian territory [19] . In our cases, the affected lobes were superior (right and left), and the intracranial metastases were in the frontal and in the occipital lobes . In none of the long-term survivors was the metastasis in the posterior cranial fossa [151 . This is in accord with the findings for brain metastases in general and may be explained in part by the greater difficulty of achieving radical surgical removal in this region [15] . The mean survival of our patients with solitary cerebral metastases of non-smallcell cancer treated with surgical resection of both lesions and successive radiotherapy of the brain was 25 .2 months . The clinical symptoms at onset were neurological in seven cases and pulmonary in four and the interval in onset between the two symptom complexes ranged from 15 days [17] to 17 months [2] . Noterman et al [19], reviewing also the reported long-term survivors, considered that latency of a year or so is a point in favor of a less harsh prognosis, provided that the primary
tumor is not small cell, the brain metastasis is solitary, and both are removed surgically . The small number of cases suggests, however, that other factors, at present unknown, are involved in such an abnormal course . Very probably the immune system plays a major role in controlling recurrences and new metastases also in the nervous system . Conceivably in such cases (as, probably, in ours), some neoplastic nidi were kept dormant by an uncertain balance between the neoplastic aggressiveness and the defensive factors of the organism. As long as this balance operated, the metastases were prevented from developing enough to give rise to clinical symptoms, and hence detection . In all cases of long-term survival, surgical removal both of the intracranial and of the lung lesion was macroscopically radical and, in around 50% of the cases, removal of the intracranial metastasis preceded that of the lung primary . In our cases, too, surgical treatment was aggressive . Surgical treatment combined with radiotherapy is the rule, particularly for brain metastasis, as confirmed by several studies [3,7,10,14,15,20,27-29] . The brain metastasis must, of course, be solitary and there should be, at the moment, no metastases elsewhere in the body [151 . A recurrence or a new localization of the metastasis is no obstacle for surgical treatment either [301, provided that these conditions are obtained . Correct staging has now been simplified by newer diagnostic procedures such as CT and magnetic resonance imaging. The latter affords better visualization of the parts of the nervous system such as the brain stem, that have proved difficult for CT, especially for firstgeneration and second-generation scanners . Thus, "surgically radical" removal of the lesions is
Long-Term Survival from Cerebral Metastasis
Surg Neurol
461
1991 ;36: 45 8-61
clearly imperative in patients with this disease, provided that their general health and the lesion sites permit . Radiotherapy of the brain is also considered essential . We believe that standard fractionation (30 Gy in 2 weeks) or 40-50 Gy in single doses of 1 .8 to 2 .0 Gy is preferable to more concentrated treatment because the risk of postradiation dementia seems lower [4-6] . For cases in which the lesion lies in surgically inaccesible areas, stereotactic radiosurgery may now be the first choice . Preliminary studies point increasingly to this procedure as an alternative to whole-brain irradiation and to open surgery in some instances [6,13] . The role of chemotherapy cannot be separated from that of the primary lesion. The addition of brain-targeted drugs at present has yielded only small increases in survival [3,10,19,27-291, while immunotherapy in protocols, including interleukin, is still under study .
References I . Bakay L . Results of surgical treatment of intracranial metastasis from pulmonary cancer. Report of a case with five years survival . J Neurosurg 1958 ;15 :338-41 . 2 . Boumghar M . Carcinomes broncho-pulmonaires reveles par une metastase cerebrale solitare. Ann Chir 1987 ;41 :100-3 . 3 . Constans JP, Redondo A, Meder JF. Metastases cerebrates, In : Cohadon F (ed) . Tumeurs du systeme nerveux er de ses envelopes . Paris : Flammarion, 1989 :750-72 . 4 . DeAngelis L, Delatrre JY, Posner JB . Radiation-induced dementia in patients cured of brain metastases. Neurology 1989;39 :789-96 . 5 . DeAngelis 1, Mandell LR, Thaler HT, Kimmel DW, Galicich JH, Fuks Z, Posner JB. The role of postoperative radiotherapy after resection of single brain metastases . Neurosurgery 1989 ;24 :798805 . 6 . de Tribolet N . comment to Noterman J, Hildebrand J, Rocmans P, Brotchi J . Survie a long terme apres ablation dune metastase cerebrate solitaire d'un cancer pulmonaire . Cas clinique et revue de Is litterature . Neurochirurgie 1990;36 :311 . 7 . Deviri E, Schachner A, Halevy A, Shalit M, Levy MJ . Carcinoma of lung with a solitary cerebral metastasis . Cancer 1983 ;52 : 1507-9 . 8 . Flavell G . Solitary cerebral metastases from bronchial carcinomata. Their incidence and a case of successful removal. Br Med j 1949 ;2 :736-7 (cited by Northfield DWC . The surgery of the central nervous system . Oxford : Blackwell Scientific, 1973 ;226) . 9 . Fried BM, Buckley RC . Primary carcinoma of the lung. IV : intracranial metastasis. Arch Pathol 1930 ;9 :483-527 . 10 . Galicich JH, Arbit E. Metastatic brain tumors . In : Youmans JR (ed) . Neurological surgery, ed 3 . Vol 5 . Philadelphia : WE, Saunders, 1990:3204-22 . 11 . Galuzzi 5, Payne PM . Brain metastases from primary bronchial carcinoma : A statistical study of 741 necropsies. Br J Cancer 1956 ;10 :408-14 . 12 . Hendricks GL Jr, Barnes WT, Hood HL . Seven-year "cure" of lung cancer with metastasis to the brain . JAMA 1972 ;220 :127 .
13 . Lindquist Ch . Gamma knife surgery for recurrent solitary metastasis of the cerebral hypernephroma : case report. Neurosurgery 1989 ;25 :802-4 . 14 . Magilligan DJ Jr, Duvernoy C, Malik G, Lewis JW Jr, Knighton R, Ausman JI . Surgical approach to lung cancer with solitary cerebral metastasis : twenty-five year's experience . Ann Thorac Surg 1986;42 :360-4 . 15 . Martini N . Rationale for surgical treatment of brain metastasis in non-small cell lung cancer . Ann Thorac Surg 1986 ;42 :357-8 . 16 . Modesri LM, Feldman RA . Solitary cerebral metastasis from pulmonary cancer . Prolonged survival after surgery . JAMA 1975 ;231 :1064 . 17 . Mosberg WH . Twelve-year "cure" of lung cancer with metastasis to the brain . JAMA 1976 ;35 :2745-6 . 18 . Mussi A, Janni A, Pistolesi M, Ravelli V, Buonaguidi R, Angeletti CA . Surgical treatment of primary lung cancer and solitary brain metastasis . Thorax 1985 ;40 :191-3 . 19 . Noterman J, Hildebrand J, Rocmans P, Brotchi J . Survie a long terme apres ablation d'une metasrase cerebrale solitaire d'un cancer pulmonaire. Cas clinique et revue de Is litterature. Neurochirurgie 1990 ;36 :308-11 . 20 . Patchell RA, Cirrincione C, Thaler HT, Galicich JH, Ho Kim J, Posner J . Single brain metastases : surgery plus radiation or radiation alone . Neurology 1986 ;36 :447-53 . 21 . Raskind R, Weiss SR, Wermuth RE . Single metastatic brain tumors : treatment and follow up in 41 cases . Ann Surg 1969 ;35 :510-15 . 22 . Russell D, Rubinstein I.J . Pathology of tumors of the nervous system, ed 5 . London : Edward Arnold, 1989 :809-54 . 23 . Salerno TA, Munro DD, Little JR. Surgical treatment of bronchogenic carcinoma with a brain metastasis . J Neurosurg 1978 ;48 :350-4 . 24 . Sarma DP, Weilbaecher TG . Long term survival after brain metastasis from lung cancer . Cancer 1986 ;58:1366-70. 25 . Schneider 5, Beya A, Zander E . Metastases cerebrates et carcinomes bronchiques . A propos d'une guerison depassant 13 ans . Rev Med Suisse Romande 1986 ;106 :757-60 . 26 . Simionescu MD . Metastatic tumor of the brain : a follow up study of 195 patients with neurosurgical considerations . J Neurosurg 1960 ;17 :361-73 . 27 . Sundaresan N, Galicich JH . Surgical treatment of brain metastases: clinical and computerized tomography evaluation of the results of treatment . Cancer 1985 ;55 :1382-8 . 28 . Sundaresan N . Galicich JH. Surgical treatment of single brain metastases from non-small cell lung cancer . Cancer Invest 1985 ;3 :107-113 . 29 . Sundaresan N, Galicich JH, Beattie EJ Jr . Surgical treatment of brain metastases from lung cancer . J Neurosurg 1983 ;58 : 666-71 . 30 . Sundaresan N, Sachdev VP, DiGiacinm GV, Hughes JEO . Reoperation for brain metastases . J Clin Oncol 1988;6 :1625-9 . 31 . Tarnoff JF, Calinog TA, Byla JG . Prolonged survival following cerebral metastasis from pulmonary cancer . J Thorac Cardiovasc Surg 1976 ;72 :933-7 . 32 . Tomlinson BE, Perry RH, Stewart-Wynne EG . Influence on site of origin of lung carcinomas on clinical presentation and central nervous system metastases . J Neurol Neurosurg Psychiatry 1979 ;42 :82-8. 33 . Zulch KJ . Brain tumors : their biology and pathology, ed 3, Berlin : Springer Verlag, 1986 :490-8 .
Surg Neurol 1991 ;36 :458-61
Solitary Cerebral Metastasis from Lung Cancer with Very Long Survival : Report of Two Cases and Review of the Literature Maurizio Salvati, M .D., Marco Artico, M .D., Simona Carloia, M .D., Epimenio Ramundo Orlando, M .D., and Franco Maria Gagliardi, M.D. Department of Neurological Sciences, Department of Neurosurgery, and Second Service of Neuroradiology, "La Sapienza" University of Rome, Rome, Italy
Salvari M, Artico M, Carloia S, Orlando ER, Gagliardi FM . Solitary cerebral metastasis from lung cancer with very long survival: report of two cases and review of the literature . Surg Neurol 1991 ;36 :458-61 .
Solitary cerebral metastases from lung cancer are not uncommon clinical events . Whatever treatment is adopted, long-term survival is rare . Very rare indeed are reports of patients surviving the discovery of lung cancer and brain metastasis for 10 years or more . Indeed, only 16 cases have been reported to our knowledge . We report two further cases, stressing the importance of correct clinicopathological staging so that treatment may be conducted in the way most likely to ensure longer and better survival and, pending a therapeutic breakthrough, to increase the number of long-term survivors . Brain metastasis ; Lung neoplasm ; Radiotherapy ; Surgery ; Chemotherapy KEY WORDS :
The brain is one of the most common sites of metastases from solid tumors of the lung and mammary gland [3,10,22,29,33] . Anywhere from 15% to 80% of lung cancers metastasize to the brain, depending on the type of series, clinical or postmortem, with a mean of about one third of all patients having a non-small-cell carcinoma of the lung [7,11,14,15,19,24] . The brain lesion is solitary, at least on first diagnosis, in 30% to 50% of cases [7,19,24}, and these are the cases most likely to respond to surgical treatment . Nonetheless, although the mean survival (for nonsmall-cell lung cancer) after surgery plus radiotherapy is decidedly longer than after radiotherapy alone, namely, 26 months versus 14 months [15] or 19 months versus 9 [20], long-term survival is rare [1,2,8,9,12,14,1619,21,23-26,31) . Address reprint requests to: Maurizio Salvati, M .D ., Via Cardinal Agliardi 15, 00165 Rome, Italy . Received February 14, 1991 ; accepted April 29, 1991 . 0 1991
by Elsevier Science Publishing Co., Inc.
We report two cases of long-term survivors after the diagnosis of adenocarcinoma of the lung and brain metastases .
Case Reports Case I A 62-year-old man gave a 15-day history of two episodes of generalized epileptic seizures . He had undergone surgery 2 months before for the removal of an adenocarcinoma of the superior lobe of the left lung . Neurological examination was normal . A computed tomography (CT) brain scan imaged a hyperdense spaceoccupying lesion in the right frontal lobe, which was enhanced on contrast injection . Perilesional edema was present (Figure 1). Surgery accomplished total removal of a grayish-red tumor, which was not on the surface and which proved on histological examination to be a metastatic adenocarcinema (Figure 2) . The postoperative course was uneventful and the patient was discharged free from neurological deficits on day 8 . He then received a course of radiotherapy (40 Gy whole brain) in addition to regional radiotherapy (60 Gy) and monochemotherapy (intravenous cyclophosphamide) for complementary treatment of the lung cancer . The patient was followed up for 11 years with numerous diagnostic procedures (including brain and total body CT scans) and showed no signs of resumption of the disease . In 1991, diffuse osseous pain and a slight dyspnea appeared. The radiodiagnostic exams showed diffuse bone metastases and relapse of lung carcinoma . Only palliative therapy was carried out and the patient died after 3 months . No autopsy was permitted .
Case 2 A 55-year-old man came to our observation in 1965 with a 2 week history of headache, vomiting (even on an empty stomach), and slowed mentation . Neurological 0090-3019191/53 .50
Long-Term Survival from Cerebral Metastasis
Surg Neurol 1991 ;36 :458-61
4 59
walnut-sized, apparently well-circumscribed lesion was found in the right occipital lobe . The removal was total from the gross point of view . Histological examination revealed a typical picture of a metastatic adenocarcinoma (Figure 3) . The postoperative course was uneventful and the patient was discharged 8 days later . Radiotherapy was given to the whole brain (45 Gy) . An oncologic screening was also performed and 20 days later an x-ray exam of the thorax confirmed by CT showed a round lesion in the left pulmonary upper lobe . The patient underwent thoracic surgery in another institution and a left pneumonectomy was done . Histological examination revealed an adenocarcinoma of the lung . Regional radiotherapy (60 Gy) was administered to the patient, who survived illness free for 10 years . He died in 1975 from multiple lung and bone recurrences of the malignancy . There was no autopsy .
Discussion
Figure 1.
Case 1 . Craniocerebral CT scan showing a right frontal mass with a perilerional edema enhanced by intravenous contrast medium .
examination revealed bilateral papilledema and a left homonymous hemianopia . Plain x-rays showed the skull to be normal and a cerebral angiography disclosed a tumor blush in the right occipital lobe . The patient was operated on and at surgery a reddish,
Solitary brain metastases do not usually spell long-term survival, and lesions arising from the lung are no exception [3,10,19,20,27-29] . Instances of 5-year survival are rarely reported, with only 34 cases having been published [1,2,8,9,12,16-19,21,23-26,31} and, of these, only 16 were reported free of disease after 10 years or more [2,7,14,17,19,23-25] . Among the 10-year survivors described in detail, males predominate in the ratio of 8 : 1 ; no patient had small-cell carcinoma. The histotypes were adenocarcinoma in six cases, squamous carcinoma in four, and large-cell carcinoma in one . The predominance of males seems to depend on the higher incidence of lung cancers among males, while the absence of small-cell tumors is in keeping with the de-
Figure
2. Care L Histological picture showing a typical adenocarcinomatous area . Cells of various aspects and sizes are visible . Mitosis is recognizable (hematoxvlin and eosin stain x200) .
460
Surg Neurol 1991 ;36 : 4 5 8-61
Salvati et al
Figure 3 . Case 2 . Histologic specimen showing an evident cellular polymorphism and various mitoses, also atypical. The adenocarcinomatous pattern is easily recognizable (hematoxylin and eosin slain X100) .
cidedly poorer prognosis of this histotype than for other lung cancers . The relative preponderance of adenocarcinomas over other histotypes is confirmed by several "general" series, although in some series they are equal in frequency to squamous or large-cell carcinomas [7,14,22,33] . Tomlinson et al [321 adduce in support of this the fact that brain metastases are more often present when the primary tumor affects the peripheral regions of the pulmonary parenchyma, often the site of adenocarcinomatous tumors . In our two cases the patients were males and the histotype was adenocarcinoma. The primary tumor in "long-term survivors" seems to prefer the superior lobe of the left lung and the intracranial metastasis tends to gravitate to the sylvian territory [19] . In our cases, the affected lobes were superior (right and left), and the intracranial metastases were in the frontal and in the occipital lobes . In none of the long-term survivors was the metastasis in the posterior cranial fossa [151 . This is in accord with the findings for brain metastases in general and may be explained in part by the greater difficulty of achieving radical surgical removal in this region [15] . The mean survival of our patients with solitary cerebral metastases of non-smallcell cancer treated with surgical resection of both lesions and successive radiotherapy of the brain was 25 .2 months . The clinical symptoms at onset were neurological in seven cases and pulmonary in four and the interval in onset between the two symptom complexes ranged from 15 days [17] to 17 months [2] . Noterman et al [19], reviewing also the reported long-term survivors, considered that latency of a year or so is a point in favor of a less harsh prognosis, provided that the primary
tumor is not small cell, the brain metastasis is solitary, and both are removed surgically . The small number of cases suggests, however, that other factors, at present unknown, are involved in such an abnormal course . Very probably the immune system plays a major role in controlling recurrences and new metastases also in the nervous system . Conceivably in such cases (as, probably, in ours), some neoplastic nidi were kept dormant by an uncertain balance between the neoplastic aggressiveness and the defensive factors of the organism. As long as this balance operated, the metastases were prevented from developing enough to give rise to clinical symptoms, and hence detection . In all cases of long-term survival, surgical removal both of the intracranial and of the lung lesion was macroscopically radical and, in around 50% of the cases, removal of the intracranial metastasis preceded that of the lung primary . In our cases, too, surgical treatment was aggressive . Surgical treatment combined with radiotherapy is the rule, particularly for brain metastasis, as confirmed by several studies [3,7,10,14,15,20,27-29] . The brain metastasis must, of course, be solitary and there should be, at the moment, no metastases elsewhere in the body [151 . A recurrence or a new localization of the metastasis is no obstacle for surgical treatment either [301, provided that these conditions are obtained . Correct staging has now been simplified by newer diagnostic procedures such as CT and magnetic resonance imaging. The latter affords better visualization of the parts of the nervous system such as the brain stem, that have proved difficult for CT, especially for firstgeneration and second-generation scanners . Thus, "surgically radical" removal of the lesions is
Long-Term Survival from Cerebral Metastasis
Surg Neurol
461
1991 ;36: 45 8-61
clearly imperative in patients with this disease, provided that their general health and the lesion sites permit . Radiotherapy of the brain is also considered essential . We believe that standard fractionation (30 Gy in 2 weeks) or 40-50 Gy in single doses of 1 .8 to 2 .0 Gy is preferable to more concentrated treatment because the risk of postradiation dementia seems lower [4-6] . For cases in which the lesion lies in surgically inaccesible areas, stereotactic radiosurgery may now be the first choice . Preliminary studies point increasingly to this procedure as an alternative to whole-brain irradiation and to open surgery in some instances [6,13] . The role of chemotherapy cannot be separated from that of the primary lesion. The addition of brain-targeted drugs at present has yielded only small increases in survival [3,10,19,27-291, while immunotherapy in protocols, including interleukin, is still under study .
References I . Bakay L . Results of surgical treatment of intracranial metastasis from pulmonary cancer. Report of a case with five years survival . J Neurosurg 1958 ;15 :338-41 . 2 . Boumghar M . Carcinomes broncho-pulmonaires reveles par une metastase cerebrale solitare. Ann Chir 1987 ;41 :100-3 . 3 . Constans JP, Redondo A, Meder JF. Metastases cerebrates, In : Cohadon F (ed) . Tumeurs du systeme nerveux er de ses envelopes . Paris : Flammarion, 1989 :750-72 . 4 . DeAngelis L, Delatrre JY, Posner JB . Radiation-induced dementia in patients cured of brain metastases. Neurology 1989;39 :789-96 . 5 . DeAngelis 1, Mandell LR, Thaler HT, Kimmel DW, Galicich JH, Fuks Z, Posner JB. The role of postoperative radiotherapy after resection of single brain metastases . Neurosurgery 1989 ;24 :798805 . 6 . de Tribolet N . comment to Noterman J, Hildebrand J, Rocmans P, Brotchi J . Survie a long terme apres ablation dune metastase cerebrate solitaire d'un cancer pulmonaire . Cas clinique et revue de Is litterature . Neurochirurgie 1990;36 :311 . 7 . Deviri E, Schachner A, Halevy A, Shalit M, Levy MJ . Carcinoma of lung with a solitary cerebral metastasis . Cancer 1983 ;52 : 1507-9 . 8 . Flavell G . Solitary cerebral metastases from bronchial carcinomata. Their incidence and a case of successful removal. Br Med j 1949 ;2 :736-7 (cited by Northfield DWC . The surgery of the central nervous system . Oxford : Blackwell Scientific, 1973 ;226) . 9 . Fried BM, Buckley RC . Primary carcinoma of the lung. IV : intracranial metastasis. Arch Pathol 1930 ;9 :483-527 . 10 . Galicich JH, Arbit E. Metastatic brain tumors . In : Youmans JR (ed) . Neurological surgery, ed 3 . Vol 5 . Philadelphia : WE, Saunders, 1990:3204-22 . 11 . Galuzzi 5, Payne PM . Brain metastases from primary bronchial carcinoma : A statistical study of 741 necropsies. Br J Cancer 1956 ;10 :408-14 . 12 . Hendricks GL Jr, Barnes WT, Hood HL . Seven-year "cure" of lung cancer with metastasis to the brain . JAMA 1972 ;220 :127 .
13 . Lindquist Ch . Gamma knife surgery for recurrent solitary metastasis of the cerebral hypernephroma : case report. Neurosurgery 1989 ;25 :802-4 . 14 . Magilligan DJ Jr, Duvernoy C, Malik G, Lewis JW Jr, Knighton R, Ausman JI . Surgical approach to lung cancer with solitary cerebral metastasis : twenty-five year's experience . Ann Thorac Surg 1986;42 :360-4 . 15 . Martini N . Rationale for surgical treatment of brain metastasis in non-small cell lung cancer . Ann Thorac Surg 1986 ;42 :357-8 . 16 . Modesri LM, Feldman RA . Solitary cerebral metastasis from pulmonary cancer . Prolonged survival after surgery . JAMA 1975 ;231 :1064 . 17 . Mosberg WH . Twelve-year "cure" of lung cancer with metastasis to the brain . JAMA 1976 ;35 :2745-6 . 18 . Mussi A, Janni A, Pistolesi M, Ravelli V, Buonaguidi R, Angeletti CA . Surgical treatment of primary lung cancer and solitary brain metastasis . Thorax 1985 ;40 :191-3 . 19 . Noterman J, Hildebrand J, Rocmans P, Brotchi J . Survie a long terme apres ablation d'une metasrase cerebrale solitaire d'un cancer pulmonaire. Cas clinique et revue de Is litterature. Neurochirurgie 1990 ;36 :308-11 . 20 . Patchell RA, Cirrincione C, Thaler HT, Galicich JH, Ho Kim J, Posner J . Single brain metastases : surgery plus radiation or radiation alone . Neurology 1986 ;36 :447-53 . 21 . Raskind R, Weiss SR, Wermuth RE . Single metastatic brain tumors : treatment and follow up in 41 cases . Ann Surg 1969 ;35 :510-15 . 22 . Russell D, Rubinstein I.J . Pathology of tumors of the nervous system, ed 5 . London : Edward Arnold, 1989 :809-54 . 23 . Salerno TA, Munro DD, Little JR. Surgical treatment of bronchogenic carcinoma with a brain metastasis . J Neurosurg 1978 ;48 :350-4 . 24 . Sarma DP, Weilbaecher TG . Long term survival after brain metastasis from lung cancer . Cancer 1986 ;58:1366-70. 25 . Schneider 5, Beya A, Zander E . Metastases cerebrates et carcinomes bronchiques . A propos d'une guerison depassant 13 ans . Rev Med Suisse Romande 1986 ;106 :757-60 . 26 . Simionescu MD . Metastatic tumor of the brain : a follow up study of 195 patients with neurosurgical considerations . J Neurosurg 1960 ;17 :361-73 . 27 . Sundaresan N, Galicich JH . Surgical treatment of brain metastases: clinical and computerized tomography evaluation of the results of treatment . Cancer 1985 ;55 :1382-8 . 28 . Sundaresan N . Galicich JH. Surgical treatment of single brain metastases from non-small cell lung cancer . Cancer Invest 1985 ;3 :107-113 . 29 . Sundaresan N, Galicich JH, Beattie EJ Jr . Surgical treatment of brain metastases from lung cancer . J Neurosurg 1983 ;58 : 666-71 . 30 . Sundaresan N, Sachdev VP, DiGiacinm GV, Hughes JEO . Reoperation for brain metastases . J Clin Oncol 1988;6 :1625-9 . 31 . Tarnoff JF, Calinog TA, Byla JG . Prolonged survival following cerebral metastasis from pulmonary cancer . J Thorac Cardiovasc Surg 1976 ;72 :933-7 . 32 . Tomlinson BE, Perry RH, Stewart-Wynne EG . Influence on site of origin of lung carcinomas on clinical presentation and central nervous system metastases . J Neurol Neurosurg Psychiatry 1979 ;42 :82-8. 33 . Zulch KJ . Brain tumors : their biology and pathology, ed 3, Berlin : Springer Verlag, 1986 :490-8 .
