Influence of site of origin of lung carcinomas on clinical presentation and central nervous system metastases

Epidemiology of brain metastases

Brain metastases are one of the most common neurologic complications of cancer. The incidence is 9%-17% based on various studies, although the exact incidence is thought to be higher. The incidence is increasing with the availability of improved imaging techniques which aid early diagnosis, and effective systemic treatment regimens which prolong life, thus allowing cancer to disseminate to the brain. Lung cancer, breast cancer, and melanoma are the most frequent to develop brain metastases, and account for 67%-80% of all cancers. Most patients with brain metastases have synchronous extracerebral metastases. Some patients present with no known primary cancer diagnosis. In children, brain metastases are rare; germ cell tumors, sarcomas, and neuroblastoma are the common offenders.

Intramedullary spinal cord metastasis: report of three cases and review of the literature

BACKGROUND

Intramedullary spinal cord metastasis is rare; but it is being encountered with increasing frequency. Optimal treatment after diagnosis remains controversial.

METHODS

In the last 3 years, we have encountered three cases of intramedullary metastasis presenting as focal mass lesions with minimal systemic evidence of cancer. We present our results in these patients and review the literature in an effort to more optimally define both the natural course of this disease, as well as a potential subset of patients who might benefit from more aggressive treatment.

RESULTS

With the availability of more sensitive imaging techniques, these tumors are being diagnosed with increasing frequency. Magnetic resonance imaging is sensitive, but nonspecific, in distinguishing intramedullary spinal cord metastases from primary cord tumors. Urgent biopsy is often necessary prior to definitive treatment. Radiation with chemotherapy significantly prolongs survival. Radical subtotal resection may offer additional quality survival, especially in cases of metastatic melanoma with an occult primary.

CONCLUSIONS

Regardless of treatment, many patients survive less than 1 year. Intramedullary spinal cord metastasis is a devastating condition, but with appropriate diagnosis and aggressive treatment, selected patients may have substantially increased survival.

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.

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.

Prognosis of resected well-differentiated neuroendocrine carcinoma of the lung

Among lung tumors, well-differentiated neuroendocrine carcinomas are often misdiagnosed or may go unrecognized. Nineteen cases of well-differentiated neuroendocrine carcinoma (WDNC) were assessed at the National Cancer Institute of Milan over a ten-year period. There was only one woman and the age range was 50 to 77 years. Most of the patients were smokers (83 percent). All tumors were radically resected. There were 12 lobectomies, two sleeve-lobectomies, three bilobectomies, one pneumonectomy, and two segmentectomies (one patient had two synchronous WDNCs). There was neither operative mortality nor major complications. Sixteen tumors were stage 1, three were stage II, and one was stage IIIa. Five patients had adjuvant chemotherapy (cyclophosphamide, doxorubicin, and vincristine [CAV] regimen). One patient was given local or regional radiotherapy. In ten patients the tumors recurred, even though four had had adjuvant treatment. The brain was the first site of metastasis in seven cases. The pathologic stage seemed not to be closely related to the appearance of metastases (six patients with stage I disease had recurrences). Only two patients with recurrence were still alive 12 and 103 months after the procedure. The percentage of survival for patients with stage I disease after more than 100 months was 68 percent. WDNC is similar to small-cell lung carcinoma (SCLC) with regard to the neurotropism of metastases. Surgery is curative for more than one half of the patients with localized disease. Therefore, multimodal therapy, probably based on tumor behavior and investigations of tumor markers, is advisable.

The role of the histologic subclassification of tumor cells in patients with small cell carcinoma of the lung and central nervous system metastases

One hundred eleven patients with small cell carcinoma of the lung (SCLC) were histologically subtyped according to the recent consensus report by the Pathology Committee of the International Association for the Study of Lung Cancer. Using pretreatment material the authors examined retrospectively the significance of subtyping of SCLC as a prognostic factor for central nervous system metastasis. The results did not reveal any significant differences between the SCLC subtypes in patients with central nervous system metastases. It was concluded that among the subtypes of SCLC significant differences with regard to the propensity for CNS metastases do not exist.

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.

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

During the years 1975 to 1980, 10 male patients and 1 female, with ages ranging between 40 to 61 years, underwent combined resection of primary lung cancer and solitary brain metastasis. In 8 patients the lung cancer was diagnosed and treated first. In those patients, craniotomy for removal of a solitary brain metastasis was carried out 8 to 60 months (mean, 27 months) after excision of the lung tumor. In 3 patients, brain metastasis was diagnosed and treated first and lung excision followed, 2 to 4 weeks after craniotomy. The most common histologic type of the tumor was adenocarcinoma (63.6%). There were no operative deaths. Three patients survived less than 6 months after surgery and were considered as a failure of surgical treatment. Seven patients lived longer than 1 year and three of them are still alive with a follow-up period between 2 to 3 1/2 years after both operations. One of the patients underwent recently successfully second brain intervention for removal of recurrent histologically identical solitary brain metastasis and is well. Our results and those reported in literature encourage the combined surgical removal of primary lung cancer and a solitary brain metastasis.

Surgical treatment of brain metastases from lung cancer

Thirty-five patients underwent surgical resection of brain metastases from non-oat-cell lung cancer between 1978 and 1981. Twenty-nine patients received postoperative radiation therapy to the brain. Twenty-three patients were male and 12 were female. Intracranial metastases occurred as the initial symptom of malignancy in 14 patients, and at varying periods following treatment of the primary tumor in 21 patients. The primary tumor and involved nodes were treated by definitive surgery in 18 patients, palliative resection and interstitial radiation in 10 patients, and by radiation therapy or chemotherapy alone in seven patients. The overall median survival time was 14 months. Favorable prognostic variables included: 1) absence of local or systemic disease at time of craniotomy (median 23 months survival time); 2) aggressive treatment of the primary tumor (median 18 months survival time); and 3) metachronous onset of brain metastases (median 15 months survival time). These survival data represent a considerable improvement over the historical 6 months median period of survival in such patients.

Metastatic carcinoma. The lung as the site for the clinically undiagnosed primary

Of 387 patients who died with lung cancer, 28 cases were reviewed (7.2%) which were clinically undiagnosed. The male:female ratio was 3.6 and mean age was 64 years in the males, 47 years in the females. The most frequent presenting symptoms were neurologic. Prior to death, 21 patients had known or suspected metastatic disease (biopsy-proven in 12), while a malignant diagnosis was not considered in seven patients. Mean survival was 3.5 months. Despite a mean tumor size of 2.8 cm, most of the chest x-rays were not diagnostic even in retrospect. At autopsy, 65% of the tumors were adenocarcinomas (compared to 32% in the other 359 patients); 53% of these showed vascular and lymphatic invasion around the primary tumor, explaining their wide dissemination. In patients with small cell carcinomas (25% of the cases reviewed) or with solitary metastases (14% of the cases reviewed) therapeutic intervention could possibly have been beneficial.

Intramedullary spinal cord metastasis

Intramedullary spinal cord metastases are rarely the presenting manifestation of a previously undiagnosed neoplasms. We report such a case in which a subacutely progressive motor and sensory spinal cord syndrome was the initial problem. The differential diagnosis and the difficulties in distinguishing intramedullary from extramedullary mass lesions are discussed. The special features of tumors of the lung and their predilection for metastasis to the central nervous system are considered.