Carcinoma of lung with a solitary cerebral metastasis. Surgical management and review of the literature

Lung Cancer with a Single Brain Metastasis: Therapeutic Options

Between January 1983 and December 1988 67 patients presenting with solitary cerebral recurrence from lung cancer were observed in our Institution. Resection was possible in 21 cases (31%). The surgical treatment included craniotomy with radical thoracotomy in 10 patients, craniotomy alone (with thoracotomy not including radical lung resection) in 5 patients and craniotomy performed within months of the initial elective thoracic surgery in 6 patients. In our series routine brain CT was carried out as a part of the staging procedure for lung cancer. Based on our results, we recommend an aggressive surgical approach to both cerebral recurrence and lung primary (scheduling craniotomy before thoracotomy), followed by whole brain RT, in order to prolong survival and improve the quality of life.

Craniotomy for brain metastases: a consecutive series of 316 patients

OBJECTIVE

To assess the incidence of craniotomy for brain metastases, overall survival (OS), surgical mortality, and prognostic factors in a large, contemporary, consecutive series from a well-defined catchment area.

MATERIAL AND METHODS

All patients ≥ 18 years who underwent craniotomies for intracranial metastases at Oslo University Hospital, Rikshospitalet and Ullevål, between 2005 and June 30, 2009 were included (n = 316). Patients were identified from our prospectively collected database and a thorough review of all charts to validate the entered data was performed.

RESULTS

The annual incidence of first-time craniotomy for a brain metastasis was 2.6/100,000 inhabitants. Patient age ranged from 25 to 87 years (median 64 years). The 30-day mortality rate was 3.8%. Median OS was 9.2 months. Recursive partitioning analysis was class I in 19.6%, class II in 59.2%, and class III in 21.2% with median OS of 16.2, 8.9, and 5.6 months, respectively (P < 0.001). Lung cancer and melanoma were associated with a higher risk (>1% per year) of developing brain metastases. Significant negative prognostic factors were age ≥ 65, a poor performance score, unstable extracranial disease, presence of extracranial metastases, multiplicity, metastasis in eloquent area, and no post-operative radiotherapy.

CONCLUSIONS

In this population study, the annual incidence of a first-time craniotomy for a brain metastasis was 2.6/100,000, the 30-day mortality rate was 3.8%, and median OS was 9.2 months. The well-known prognostic factors were confirmed.

Pronostic factors of synchronous brain metastases from lung cancer

BACKGROUND

The prognosis of brain metastases (BM) from lung cancer is poor. The management of lung cancer with BM is not clear. This retrospective study attempts to determine their prognostic factors, and to better define the role of different treatments.

METHODS

We reviewed the clinical characteristics of 271 consecutive patients with synchronous brain metastases (SBM) from lung cancer (small-cell lung cancers and non-small-cell lung cancers), collected between January 1985 and May 1993. Data were available for all patients as well as follow-up information on all patients through to death. Patients had all undergone heterogeneous treatments. Each physician had chosen the appropriate treatment after collegiate discussion. Survival curves were compared using the log-rank test in univariate analysis, and Cox's Regression model in multivariate analysis. Statistical significance was defined as P<0.05.

RESULTS

249 patients were assessable. Treatments included: neurosurgical resection in 56 cases, brain irradiation in 87 cases, and chemotherapy in 126 cases. Median overall survival time from the date of histological diagnosis of SBM was 103 days (range, 1-1699). In multivariate analysis, prognostic factors for longer overall survival times were: absence of adrenal metastases (P=0.007), neurosurgical resection (P=0.028), chemotherapy (P=0.032) and brain irradiation (P=0.008). Moreover, risk factors of intracranial hypertension as cause of death were number of SBM and absence of neurosurgical resection.

CONCLUSIONS

These results and others suggest that patients with SBM from lung cancer be considered for carcinologic treatment, and not only for best supportive care. However, further studies are necessary to evaluate quality of life with or without carcinologic treatment.

Dose optimization and indication of Linac radiosurgery for brain metastases

PURPOSE

The authors have examined treatment effects of linear accelerator based radiosurgery for brain metastases. Optimal doses and indications were determined in an attempt to improve the quality of life for terminal cancer patients.

METHODS AND MATERIALS

Ninety-two patients with 162 lesions were treated with Linac radiosurgery for brain metastases between April 1993 and September 1998. To determine prognostic factors, risk factors for recurrence, and appearance of new lesions, univariate and multivariate analyses were performed. To compare the local control between the high-dose (minimum dose > or =25 Gy: prescribed to the 50-80% isodose line) and low-dose (minimum dose <25 Gy) irradiated groups, matched-pairs analysis was performed.

RESULTS

Median survival time was 11 months. In univariate analysis, extracranial tumor activity (p<0.001) and Karnofsky Performance Status (KPS) (p = 0.036) were two significant predictors of survival. In multivariate analysis, the status of an extracranial tumor was the single significant predictor of survival (p = 0.005). Minimum dose was the single most significant predictor of local recurrence in univariate, multivariate, and matched-pairs analyses (p<0.05). As to the appearance of new lesions, activity of extracranial tumors was a significant predictor (p<0.05). Side effects due to radiosurgery were experienced in 4 of 92 cases (4.3%).

CONCLUSIONS

We concluded that brain metastases patients should be irradiated with > or =25 Gy, when extracranial lesions are stable and longer survival is expected. Combined surgery and conventional radiation may have little advantage over radiosurgery alone when metastatic brain tumors are small and extracranial tumors are well controlled. When extracranial tumors are progressive, the rate of appearance of new lesions in other nonirradiated locations becomes higher. In such cases, careful follow-up is required and a combination with whole brain irradiation should be considered.

Cytopathologic evaluation of lung carcinomas presenting as brain metastasis

Brain metastasis is an uncommon initial presentation of lung carcinoma. One arm of this analysis is a retrospective review of 137 cases of surgically diagnosed solitary brain metastasis, which were eventually found to be of lung origin, encountered at Hines VA Hospital during the period 1958 to 1996. The second arm is composed of fine-needle aspiration biopsy specimens of primary lung tumor in 23 patients with an initial clinical diagnosis of brain metastasis and without the benefit of surgery, seen from 1981 through 1996. Our results in both analyses indicate that pulmonary adenocarcinoma is the predominant primary tumor that initially manifests as a brain metastasis, approaching 76% (107 and 17 cases, respectively), followed by small-cell carcinoma at 20% (24 and five cases, respectively) and large-cell undifferentiated carcinoma and squamous-cell carcinoma at 2% each. The predominance of adenocarcinoma as a source of brain metastasis in lung cancer patients probably reflects its rising incidence overall of late. Collateral findings also suggest that surgical resection of a solitary and small brain metastasis as well as of a discrete lung primary, whenever feasible, as the most effective procedure to improve survival and quality of life of patients.

Solitary brain metastases from non-oat cell lung cancer: clinical and prognostic features

The authors report 91 cases of solitary brain metastasis from non-oat cell lung cancer, 66 patients were males and 25 females; average age was 57 years (range 40-72 years). Surgical removal was total in 80 cases and partial in 11. All patients received postoperative radiotherapy and 40 chemotherapy. Histologically, the tumor was an adenocarcinoma in 51 cases (56%), a squamous cell carcinoma in 22 (24%), an undifferentiated carcinoma in 18 (20%). Median survival was 16 months and the main cause of death was progression of the primary cancer (59% of cases). Survival was influenced by staging of the primary tumor, while no prognostic significance was found regarding the type of clinical tumor onset, type of radiotherapy and the histotype of the lesion. Use of the "no internal touch" technique and brain radiotherapy reduced local brain relapse.

Long-term survival following surgical treatment of solitary brain metastasis in non-small cell lung cancer

Dissemination of lung cancer beyond the intrathoracic lymph nodes (stage IV disease) implies surgical unresectability. However, solitary brain metastases (SBMs) from non-small cell lung cancer (NSCLC) have often been treated by combined resection of the primary tumor and its metastasis. Such an aggressive approach appears to substantively improve patient outcome and provide better quality of life in selected cases. A search of the literature reveals extended survival (10 years or longer) in 16 patients following combined surgical excision. We report three patients with NSCLC and isolated central nervous system involvement who achieved exceptionally long survival. The existing literature on SBMs from NSCLC is reviewed.

Cranial computed tomography as a part of the initial staging procedures for patients with non-small-cell lung cancer

With the possible exception of chemotherapy for the small-cell type, a complete surgical excision is still the only effective treatment of lung cancer. Routine brain computed tomography (CT) for staging purposes has been both advocated and opposed. In this retrospective study, we aimed to assess the clinical yield of the technique. We saw 184 consecutive patients with a new histologically proven non-small-cell lung cancer. Using as reference criteria clinical judgment supported by a strict follow-up evaluation, we counted 1 false- and 23 true-positive brain CT results, plus 2 false- and 158 true-negative findings. These figures allow for sensitivity, specificity, and accuracy of 92 percent, 99 percent, and 98 percent. The frequency of brain metastases did not correlate with the various histologic types, even though adenocarcinoma was the most common cause of cerebral metastases. The absence of neurologic symptoms did not exclude cerebral involvement: in our experience, 16 of 25 patients with positive brain CT scans were asymptomatic (64 percent). Three of 31 subjects (10 percent) with an otherwise operable carcinoma were found to have metastases after brain CT. We conclude that routine cranial CT is useful in the staging evaluation of the patient with non-small-cell lung cancer (NSCLC) and that it should be performed in any candidate prior to surgical resection.

Cost and survival analysis of metastatic cerebral tumors treated by resection and radiation

The surgical treatment of metastatic brain tumors remains controversial, primarily because of the limited prognosis of patients with metastatic cancer. The cost effectiveness of even standard therapies is of increasing concern to third-party payers. We reviewed the records of patients who had a single metastatic brain tumor resected at the Medical Center Hospital of Vermont (a referral center in a rural state) since cost data recording began. The 32 patients ranged in age from 35 to 77 years, with a 2.2:1 female-to-male ratio. Thirty-four percent of tumors originated in the lung, 15.6% were renal, 12.5% were breast, 12.5% were gynecological, 9.4% were gastrointestinal, and 9.4% were ultimately of unknown origin. Thirty-one tumors were completely resected; 30 patients were irradiated, most after surgery (mean dose, 3,908 +/- 1,250 cGy). Karnofsky scores improved from 80 +/- 11 to 88 +/- 16 postoperatively (P = 0.0038, one-tailed paired t-test). Patients were hospitalized an average of 8.22 +/- 6.26 days postoperatively, with total operative and postoperative charges of $19,190 +/- 5,684, noninclusive of radiotherapy. The expected median survival of all patients was 26 months (Kaplan-Meier estimate). The presence of disseminated disease was not significantly correlated with survival (P = 0.237). The number of postoperative days was more for patients with disseminated disease (P = 0.0274), but not for patients with infratentorial tumors (P = 0.6991). Age higher than the median was not correlated with an increased number of postoperative days (P = 0.1366) nor was a preoperative Karnofsky score of 70 or less (P = 0.1382).(ABSTRACT TRUNCATED AT 250 WORDS)

Cerebral imaging in the asymptomatic preoperative bronchogenic carcinoma patient: is it worthwhile?

The issue of screening for cerebral metastatic disease in the preoperative bronchogenic carcinoma patient remains unsettled and changes with advancing technology. A prospective nonrandomized study was designed to compare contrast magnetic resonance imaging (MRI) with computed tomography (CT) after several clinical situations suggested improved sensitivity for the former study. Patients with clinically operable disease and normal neurologic examinations were referred for both enhanced cerebral CT and MRI studies. Forty-two patients were entered and completed the enhanced CT scan; only 30 tolerated the MRI. The demographic data and histology of the patients appeared fairly typical for a series of operative candidates. No unsuspected metastatic lesion was found in this selected and low-risk group. We conclude that neither MRI nor enhanced CT scan is indicated in the asymptomatic bronchogenic carcinoma patient due to expense and lack of positive findings. Magnetic resonance imaging demonstrated more subtle benign pathology, but this study did not allow comparison of the two techniques in detection of metastatic disease.

Management of metastatic brain tumors

BACKGROUND

Brain metastases are the most common neurological complication of systemic cancer. They represent a serious cause of morbidity and mortality and a significant challenge for neurosurgeons. They outnumber all other intracranial tumors combined and, with advances in technology and treatment of systemic cancer, are on the increase as cancer patients live longer.

METHODS

We have reviewed the major factors that influence the occurrences of metastases in the central nervous system: primary cancer, patient age and sex, clinical aspects of presentation, basic diagnostic modalities, diagnostic imaging (computed tomography and magnetic resonance imaging), and treatment considerations. In discussing these different aspects, we emphasize the efficacy of different treatment options, including recent information regarding multiple metastases that broadens the scope of surgical implications. The criteria we present are directed toward considerations made by general surgeons, as well as those made by neurosurgeons.

CONCLUSIONS

Although radiotherapy remains the main therapeutic modality, surgical excision has increasingly shown advantages in certain settings, as has stereotactic radiosurgery. Chemotherapy is less effective, but its advantages are reviewed, as are the implications of recurrent metastases.

Craniotomy and thoracotomy for non-small cell carcinoma of the lung with cerebral metastasis

Twenty patients with non-small cell carcinoma of the lung who had cerebral metastasis, were treated by craniotomy and thoracotomy. Eighteen of these patients had a solitary metastasis and all were treated as curable. Ten patients presented with synchronous lung and brain disease. Of the remaining 10, nine initially presented with the lung tumour, which was treated first. There was a zero operative mortality rate and median survival was 12 months with reasonable quality of life for this time.

Surgical treatment for higher stage non-small cell lung cancer

Locally advanced lung cancer (stage IIIa, IIIb) in which the primary tumor is proximal (T3) or has invaded adjacent structures (T3) or organs (T4) or in which mediastinal lymph nodes are involved (N2, N3) worsens the prognosis significantly. However, in stage IIIa (T3 or N2), when surgical treatment results in total removal of the primary tumor and involved lymph nodes, there still is a reasonable chance for ultimate cure. On the other hand, total excision can be very rarely performed in T4 or N3 tumors. Therefore, this group (stage IIIb) usually indicates unresectability. Disseminated lung cancer with distant metastasis (stage IV) is still considered to be incurable. Nevertheless, solitary metastatic sites (M1), especially brain, have been treated on occasion by resection of the primary tumor and removal of the solitary metastasis. This appears to improve median survival and does yield 5-year survival in selected patients. The results after surgical treatment in these patients with higher stage lung cancer reported over the last 10 years are reviewed.

Preoperative computed tomography of the brain in non-small cell bronchogenic carcinoma

BACKGROUND

Computed tomography of the brain is the most accurate diagnostic investigation for detecting intracranial tumours. A prospective study was undertaken to try to maximise the cost effectiveness of computed tomography of the brain in the preoperative evaluation of non-small cell lung cancer.

METHODS

All patients with non-small cell lung cancer who were free of neurological symptoms and were thought to be free of metastases from the results of routine investigations were subjected to computed tomography of the brain in the 12-24 hours immediately before surgery.

RESULTS

Of 158 such patients, five showed positive evidence of metastases, confirmed on craniotomy and excision biopsy; one of these patients was found to have a non-metastatic tumour (false positive). Five patients with a negative scan who underwent lung resection returned within 12 months with neurological defects and positive findings on further computed tomography (false negative). The predominant cell type in patients with positive and false negative scans was adenocarcinoma or adenosquamous carcinoma (7/10); the majority had nodal state N2.

CONCLUSIONS

Computed tomography of the brain should be carried out if mediastinal disease is suspected or confirmed in non-small cell lung cancer before proceeding to surgery.

Solitary cerebral metastasis from lung cancer with very long survival: report of two cases and review of the literature

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.

Results and prognostic factors of surgery in the management of non-small cell lung cancer with solitary brain metastasis

Between 1975 and 1988, 37 patients with resectable non-small cell lung cancer (NSCLC) and synchronous (within 1 month, n = 10) or metachronous (n = 27) solitary brain metastasis (SBM) underwent combined excision of their lesions. Overall 5-year and median survival were 30% and 27 months (range, 3 to 125+ months), respectively. Twenty-seven patients had a relapse, and their median disease-free interval (DFI) was 17.5 months (range, 1 to 108 months). The most frequent (78%, n = 20) site of first recurrence locally was either the ipsilateral thorax (n = 14) or brain (n = 6). In univariate analysis, age, primary tumor and lymph node status; tumor histology, size, and side; type of pulmonary resection; side and location of SBM; and onset of presentation did not affect survival and DFI. By contrast, the interval (less than or equal to versus greater than 12 months) between the two operations significantly affected survival (P = 0.0096) and DFI (P = 0.046). The DFI was also affected by the administration of adjuvant chemotherapy (AC) for the primary tumor (P = 0.02). Using the Cox model, AC was the most independent predictor of DFI. These data support the inclusion of surgery in the therapeutic armamentarium for patients with NSCLC and SBM.

Cerebral metastases as first symptom of bronchogenic carcinoma. A prospective study of 37 cases

Among the patients showing evidence of cerebral metastases without previously known cancer history, lung cancer has been found 37 times as the primary tumor in our institution. There were 34 men and three women and all but two were heavy smokers. Only one presented at diagnosis with thoracic symptoms but the chest radiograph was abnormal in 34. The histologic type of the primary tumor was obtained in 32 cases as a result of thoracic investigations and in five cases from metastatic tumor tissue. The primary tumor appeared to be non-small cell lung carcinoma in 26 cases and small cell lung carcinoma in 11 cases. These results show that patients treated with surgery (20 cases) have a better survival (median 10 months versus 4.5) than the others, and among surgically treated patients only those treated with bifocal resection (eight patients) are long-term survivors. Also, in four of six patients, objective regression of the neurologic symptoms was seen after radiation therapy alone. Central nervous system relapse was seen in 12 patients, but in none of the patients treated with postoperative radiation therapy. Conventional chemotherapy (11 patients) induced objective responses only in the small cell type and proved to be too toxic when used simultaneously with radiation therapy in inoperable patients.

Surgery in bronchial carcinoma with metastasis

Two groups of lung cancer patients with solitary M1 disease are presented in whom lung resection was performed at the time of or after operative treatment of the metastasis. Nine patients had solitary brain metastasis prior to the resection of the primary tumor. Six died, with an average survival of 10 months post-thoracotomy, 3 survive after 15 to 31 months. The results are less favorable than suggested by the literature where often cases are included which have brain metastasis after lung cancer surgery. Another eight M1 situations in this series are predominantly lung cancers with pleural disease. Improvement of quality of life and substantial survival times have been observed, though most patients are still at risk after a survival of from 15 to 35 months. As to the histological features, adenocarcinoma was the most frequent type followed by the adenosquamous variant. Lung surgery should be considered in selected cases in spite of known or formerly treated solitary distant metastasis.

Surgical treatment of primary lung cancer and solitary intracranial metastasis

From 1976 through 1986, 12 patients underwent 14 thoracotomies (two patients had a second thoracotomy for recurrence) and 16 craniotomies (two patients had three craniotomies for recurrence) for carcinoma of the lung and solitary intracranial metastasis. Age ranged from 40 to 65 years. Adjuvant therapy (chemotherapy and thoracic irradiation) was employed in three patients prior to thoracotomy and in four patients following thoracotomy. Whole-brain irradiation was used in four patients after craniotomy. Improvement in neurologic symptoms following craniotomy was noted in 15 of 16 instances. There were no operative mortalities. Overall survival from the time of initial diagnosis ranged from 13 to 63 months. Survival following initial craniotomy ranged from 12 to 56 months. Eight patients are currently alive and well with no disabling neurological symptoms. These results support an aggressive approach to the resection of solitary brain metastasis from bronchogenic carcinoma, both for palliation and prolongation of survival.

Single brain metastasis of non-small cell lung carcinoma. Study of survival among 54 patients

We studied 54 patients treated for non-small cell lung carcinoma with single brain metastasis presenting between 1980 and 1985. Better survival was obtained in cases of patients presenting a fair neurological condition who were treated by surgery. Histological condition and date of onet of metastasis had no significant influence on survival. Combined treatment of both primary lung tumour and brain metastasis was a favourable prognosis element, and surgical resection of both locations led to the best results in terms of duration and quality of survival.

Surgical management of lung cancer with solitary cerebral metastasis

Between 1964 and 1986, 19 patients underwent resection of both a primary lung cancer and the associated brain metastasis. One patient underwent resection of 2 separate primary lung cancers and the associated metastases. The 12 men and 7 women ranged in age from 42 to 67 years (mean, 54.6 years). The cell type was adenocarcinoma in 12 tumors, squamous or adenosquamous cell in 5, large cell undifferentiated or anaplastic in 2, and malignant carcinoid in 1 tumor. The types of resection were as follows: lobectomy for 12 neoplasms, pneumonectomy for 5, bilobectomy for 2, and wedge resection for 1 neoplasm. Radiotherapy to the brain was given in connection with sixteen of the twenty craniotomies. The patient with 2 separate primary neoplasms survived 19 years before dying 5 months after the second craniotomy. The mean survival is 8.0 +/- 2.1 years (+/- the standard error), and the median survival is 1.67 years. Survival at 1 year was 65 +/- 10.7% and at 5 years, 45 +/- 11.1%. On univariate analysis, the following factors were found to correlate significantly with longer survival: a lung tumor in Stage I or II; negative mediastinal nodes; curative rather than palliative resection of the lung tumor; and age younger than 55 years. However, on multivariate analysis, only curative resection was a significant factor (p less than 0.01). We believe these results justify continued application of this combined surgical approach to patients having limited-stage lung cancer with a solitary brain metastasis.

Site preference of metastatic tumours of the brain

Amongst 15,000 autopsies performed between 1969 and 1984 in the Department of Pathology of the University Hospital of Innsbruck (Austria) 237 cases (1.6%) with brain metastases were found. The mean age of patients was 61.2 years and 148 patients out of 230 cases with satisfactory records were male (64.3%). Multiple lesions were found in 58%. In absolute figures carcinoma of the lung, followed by malignant melanoma and breast carcinoma were, as in other series, the most frequent primary site for brain metastases. The relative frequency of brain metastases in various anatomical regions of the brain showed that malignant melanoma tends to metastasize to the frontal and temporal lobes, breast carcinoma to the cerebellum and the basal ganglia, large cell carcinoma of the lung to the occipital lobe and squamous cell carcinoma of the lung to the cerebellum. Metastases of small cell carcinoma of the lung were found equally distributed in all regions of the brain. Our study supports the results of several experimental investigations, suggesting the possibility that specific cell surface properties of metastasizing tumour cells and particular properties of the vascular endothelium of the target organs of metastasis are responsible for the location of metastases. The results of this study suggest that there are substantial differences in regard to these properties even within one target organ.

Neurologic disorders in patients with small cell lung cancer

In a series of 641 patients with small cell lung cancer, 189 (29.5%) had at least one neurologic disorder either at the time of presentation or during the subsequent clinical course of the cancer. The total number of neurologic disorders was 210, which included brain metastases (75.7%), meningeal carcinomatosis (6.7%), intramedullary metastases (2.4%), epidural metastases (11.0%), hyponatremia producing CNS symptoms (3.3%), and Eaton-Lambert syndrome (1.0%). The most common signs and symptoms were motor dysfunction and confusion. The overall survival of patients with any neurologic disorder was compared to that of patients without neurologic problems. There was no difference between the survival curves for the first year and a half, but patients without neurologic complications had a greater probability of long-term survival (log-rank P = 0.03). There were no statistically significant differences when this comparison was made according to stage of disease. When a neurologic disorder related to cancer occurred, the survival time from the date of that diagnosis was usually short. The neurologic disorder was the immediate cause of death in the majority of cases. In patients who achieved a complete remission, the administration of prophylactic cranial irradiation (PCI) significantly reduced the risk of developing brain metastases as the initial site of the relapse (log-rank P = 0.0034). After adjustment for performance status and extent of disease, the survival of complete responders treated with and without PCI was not significantly different. We conclude that neurologic complications are a frequent and serious problem in patients with SCLC.

Surgical approach to lung cancer with solitary cerebral metastasis: twenty-five years' experience

From 1960 to 1985, 41 patients underwent resection of a lung cancer and one or more brain metastases. There were 24 men and 17 women ranging in age from 40 to 71 years (average, 56 years). Cell type was adenocarcinoma in 19 patients, squamous in 16, small cell in 4, and large cell in 2. Wedge resection was performed in 4 patients, lobectomy in 20, pneumonectomy in 14, and bilobectomy in 3. Brain irradiation was used for 25 patients (61%). To date, the longest survival is 18.3 years after craniotomy; mean survival is 2.3 years +/- 3.8 (+/- standard deviation). Survival was 55 +/- 7.9% (+/- standard error) at 1 year, 31 +/- 7.4% at 2 years, 21 +/- 6.5% at 5 years, and 15 +/- 6.0% at 10 years. Using multivariate analysis, we evaluated possible significant predictors of improved survival. Only wedge resection was a significant predictor (p less than .01), which suggests better results with a small peripheral lung tumor. Results of our 25 years' experience using an aggressive approach to lung cancer with solitary cerebral metastasis indicate significantly improved patient survival that justifies its widespread use.

Non-small cell lung cancer. Neuroresection of the solitary intracranial metastasis followed by radiochemotherapy

Fifteen selected patients with advanced intrathoracic non-small cell lung cancer and solitary metastasis were treated by a combined program including craniotomy, brain and chest irradiation, and systemic chemotherapy. One patient died because of cerebral hemorrhage after the operation. Five patients failed to achieve neurologic benefit. Nine patients improved their neurologic grading, and the median duration of improvement was 10 months (range, 1-26 months). The responses to systemic treatment were: one complete response, three partial responses, six stable disease responses, and four progressive disease responses. The overall median survival was 6 months from craniotomy and 12 months from diagnosis. Five patients became long survivors; they had a survival time ranging between 12 and 26 months after craniotomy. In conclusion, one third of patients had a satisfactory response to treatment; this outlines the value of the combined aggressive therapeutic approach also performed in patients who had a highly unfavorable prognoses.

Surgical treatment of single brain metastases from non-small-cell lung cancer

We analyzed the results of surgical treatment of 50 patients with brain metastases from non-small-cell lung cancer who underwent craniotomy between the years 1978 through 1983. The onset of brain metastases was synchronous in 14 patients, occurred within 1 year of treatment of the primary tumor in 21 patients, and after 1 year in 15 patients. A total of 28 patients had undergone curative resection of the lung tumor; 15 patients had undergone palliative resection with or without radioactive implants, and 7 patients did not undergo surgical treatment of their primary tumor. At time of craniotomy, 31 patients were considered to have disease limited to the central nervous system. Following surgery, 34 patients received radiation therapy (30 whole brain radiation, 4 focal radiation); 15 patients had previously undergone whole brain radiation ("radiation failures"), and there was 1 postoperative death. The overall median survival in this series was 18 months. Favorable prognostic variables included (a) curative resection of the primary tumor (median 28 months), (b) disease limited to the central nervous system (median 24 months), and (c) negative mediastinal nodes at time of thoracotomy (median 28 months). The incidence of local recurrence of intracranial tumor at the original site was higher in those patients who had failed previous radiation (53%) compared to those who received postoperative radiation (12%). Although the overall degree of neurological palliation was 75%, patients who had failed radiation were less successfully palliated, and the majority continued to require steroid therapy following tumor resection. These results suggest that patients with single brain metastases from non-small-cell lung cancer who have undergone curative resection of their primary tumor have considerable potential for long-term survival, and surgical resection prior to radiation should be considered. Even in symptomatic patients with controlled or limited extracranial disease, such treatment provides rapid effective neurological palliation and can be accomplished currently with minimal mortality and morbidity.