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Prolonged Survival After Neurosurgical Resection of Lung Cancer Metastasis

Prolonged Survival After Neurosurgical Resection of Lung Cancer Metastasis 10.2478/chilat-2014-0106 ACTA CHIRURGICA LATVIENSIS • 2014 (14/1) CASE REPORT Prolonged Survival after Neurosurgical Resection of Lung Cancer Metastasis Gvido Janis Bergs*, Raimonds Bricis**, Arvids Jakovlevs*, Andrejs Vanags*, Ilze Strumfa* *Riga Stradins University, Latvia **Pauls Stradins Clinical University Hospital, Latvia SUMMARY Metastatic tumours in the brain occur more frequently than primary neoplasms. Despite the generally dismal prognosis, neurosurgical resection is indicated in certain patients and can yield prolonged survival. Here we describe an 82-year-old male with a history of neurosurgical resection of a single brain metastasis 6 years ago. Tumour immunophenotype disclosed lung adenocarcinoma with low proliferation fraction. However, the primary tumour remained occult then. At present, 3 new brain metastases were identified by computed tomography. Repeated resection was performed in 2 stages, resulting in removal of 2 metastases. Lung mass was now evident as well. The final diagnosis was lung adenocarcinoma with metachronous brain metastases, stage IV. In conclusion, prolonged survival, in this case 6 years, can be reached even in patients with metastatic cancer by successful selective application of neurosurgical treatment. The biological properties of the tumour including low proliferation also contributed to longer survival and demonstrated surgery as a successful treatment option. Key words: brain metastasis, neurosurgical resection, lung cancer, prolonged survival AIM OF THE DEMONSTRATION in the basal part of temporal lobe, measuring 3 mm. The In order to broaden the awareness of up-to-dated chest CT showed pathologic mass in right upper pulmonary neurosurgical treatment possibilities, here we report lobe, measuring 3.4x2.8 cm (Fig. 1B). Craniotomy was a well-documented case of prolonged survival due to performed in 2 steps. At first, left frontal bone craniotomy neurosurgical resection of brain metastasis in a patient provided access for resection of metastasis from frontal lobe with stage IV lung cancer. using neuronavigation. The second step included resection of parietal lobe metastasis, using neuronavigation from CASE REPORT different approach. The first step lasted 70 minutes, the An 82-year-old male was transferred to a clinical second – 115 minutes. Metastasis in temporal lobe was university hospital for elective brain metastasis resection. considered not accessible. The post-operative period was The patient complained of weakness in the right hand smooth. The histological examination of surgical material and leg as well as tightness in left side of face during the showed high-grade adenocarcinoma (Fig. 2A) expressing previous 8 months. Ten days before the admission, the the following immunohistochemistry (IHC) markers: patient felt dizzy and collapsed. He was admitted to a cytokeratins CK7 (Fig. 2B) and CKAE 1/3 as well as TTF-1, regional hospital. Computed tomography (CT) of the brain diagnostic of primary lung cancer. Six years ago histological revealed a mass lesion in left parietal lobe (Fig. 1A) thus examination of metastasis from right frontal lobe showed the patient was transferred for neurosurgical treatment. intermediate-grade papillary adenocarcinoma expressing He had a history of neurosurgical resection of a single the same IHC markers. The proliferation fraction of cancer brain metastasis in right frontal lobe 6 years ago. Tumour was 9.6% (Fig. 2C) in the first event, increased now to immunophenotype yielded lung adenocarcinoma with 36.7% (Fig. 2D). Thus, the cancer has transformed to low proliferation fraction. However, the primary tumour higher grade and significantly higher proliferation fraction. remained occult then as the chest CT was negative at that The higher grade was characterised by increased nuclear time. The medical history included also brain infarction polymorphism and by loss of papillary architecture (Fig. in the left middle cerebral artery basin 6 years ago and 2E) resulting in solid sheets of neoplastic cells (Fig. 2F). moderate primary arterial hypertension. The final diagnosis was lung adenocarcinoma with At present, the general condition was estimated as average. metachronous brain metastases, stage IV. The patient was The Glasgow coma scale score was 15. Neurological transferred back to regional hospital for further recovery. Oncologist council recommended symptomatic therapy examination revealed lower reflexes and positive Babinski’s sign on the right side. The arterial pressure under the guidance of family doctor. was 150/85 mmHg, the heart rate – 74 times per minute. Breathing sounds were normal having the frequency of 17 DISCUSSION times per minute. Both primary and metastatic tumours can affect the brain. Brain metastases outnumber primary neoplasms The contrast-enhanced CT of head and brain showed 3 mass lesions in the left hemisphere: in parietal lobe, by at least 10 to 1, and they occur in 20% to 40% of measuring 2x1.5 cm; in frontal lobe, measuring 5 mm and cancer patients. About 80% of metastases are located in 32 ACTA CHIRURGICA LATVIENSIS • 2014 (14/1) the cerebral hemispheres, 15% in the cerebellum, and 3. El Kamar FG, Posner JB. Brain metastases // Semin 5% in the brainstem. In a retrospective neurosurgical Neurol, 2004; 24:347 – 362 review, 45.6% of the patients had solitary brain metastasis 4. Fujimaki T. Surgical treatment of brain metastasis // without other systemic metastases, 26.5% had single Int J Clin Oncol, 2005; 10:74 – 80 brain metastasis along with other metastases, and the rest 5. Kalkanis SN, Kondziolka D, Gaspar LE, Burri SH, had two or more brain metastases. The most common Asher AL, Cobbs CS, Ammirati M, Robinson PD, primary cancer metastasizing to the brain is lung cancer Andrews DW, Loeffler JS, McDermott M, Mehta MP, that is responsible for 50% of all metastasis (Patchell, Mikkelsen T, Olson JJ, Paleologos NA, Patchell RA, 2003; El Kamar and Posner; 2004; Stark et al., 2011). Ryken TC, Linskey ME. The role of surgical resection Neurosurgical resection is recommended for patients with in the management of newly diagnosed brain a single accessible brain metastasis, especially when the metastases: a systematic review and evidence-based tumour size is large causing a considerable mass effect clinical practice guideline // J Neurooncol, 2010; or obstructive hydrocephalus. Surgery is also favoured 96:33 – 43 in patients with good performance status, who are 6. Kanou T, Okami J, Tokunaga T, Fujiwara A, Ishida functionally independent and in whom systemic disease D, Kuno H, Higashiyama M. Prognosis associated is limited or absent and for patients with radioresistant with the surgery for non-small cell lung cancer and primary tumour (Kalkanis et al., 2010). Multiple brain synchronous brain metastasis // Surg Today, 2014; metastases in most cases represent a contraindication for 44:1321 – 1327 neurosurgical treatment and resection is recommended 7. Lutterbach J, Bartelt S, Ostertag C. Long-term survival only for the dominant lesion (Paek et al., 2005). Multiple in patients with brain metastases // J Cancer Res Clin metastases can be handled in a single operation if they are Oncol, 2002; 128:417 – 425 located in the same hemisphere and are close to each other 8. Nussbaum ES, Djalilian HR, Cho KH, Hall WA. Brain (Fujimaki, 2005). Recurrent brain metastases develop in metastases. Histology, multiplicity, surgery, and 31 – 48% of neurosurgically treated patients, the median survival // Cancer, 1996; 78:1781 – 1788 survival is 4 months and 2-year survival is less than 6% 9. Paek SH, Audu PB, Sperling MR, Cho J, Andrews (Bindal et al., 1992; Nussbaum et al., 1996; Lutterbach et DW. Reevaluation of surgery for the treatment al., 2002). Despite the generally short survival of patients of brain metastases: review of 208 patients with affected by brain metastases of lung cancer (D’Antonio single or multiple brain metastases treated at one et al., 2014), longer survival has been reported as well institution with modern neurosurgical techniques // (Kanou et al., 2014). Neurosurgery, 2005; 56:1021 – 1034 The known prognostic factors for prolonged survival after 10. Patchell RA. The management of brain metastases // surgery in patients with non-small cell lung cancer and Cancer Treat Rev, 2003; 29:533 – 540 synchronous brain metastasis include small size of primary 11. Sica G, Yoshizawa A, Sima CS, Azzoli CG, Downey RJ, tumour and lack of lymph node involvement (Kanou et Rusch VW, Travis WD, Moreira AL. A grading system al., 2014). As the primary cancer in our patient remained of lung adenocarcinomas based on histologic pattern occult by CT, such characteristics can be hypothetically is predictive of disease recurrence in stage I tumors // assumed. In addition, the presented case was characterised Am J Surg Pathol, 2010; 34:1155 – 1162 also by initially low proliferation fraction that could 12. Stark AM, Stohring C, Hedderich J, Held-Feindt J, supposed to be associated with limited tumour spread. Mehdorn HM. Surgical treatment for brain metastases: However, conversion to high-grade (Sica et al., 2010) Prognostic factors and survival in 309 patients with adenocarcinoma with notably higher proliferation fraction regard to patient age // J Clin Neurosci, 2011; 18:34 – 38 followed. In conclusion, here we show a patient benefitting from prolonged survival of 6 years after successful neurosurgical Address resection of solitary lung cancer metastasis. The biological Ilze Strumfa properties of the tumour including low proliferation at the Department of Pathology, Riga Stradins University Dzirciema Street 16, LV-1007, Riga, Latvia first occurrence could contribute to longer survival and demonstrated surgery as a successful treatment option. E-mail: Ilze.Strumfa@rsu.lv The case is also notable for successful application of IHC detecting the tumour origin before it was radiologically visible. Conflict of interest: None REFERENCES 1. Bindal RK, Sawaya R, Lee JJ. Surgical treatment of multiple brain metastases // J Neurosurg, 1993; 79:210 – 216 2. D’Antonio C, Passaro A, Gori B, del Signore E, Migliorino MR, Ricciardi S, Fulvi A, de Marinis F. Bone and brain metastasis in lung cancer: recent Fig. 1. Computed tomography (CT) findings. 1A, advances in therapeutic strategies // Ther Adv Med Brain CT showing mass lesion in the left parietal Oncol, 2014; 6:101 – 114 lobe. 1B, Chest CT revealing a pathological mass in the right upper lobe. 33 ACTA CHIRURGICA LATVIENSIS • 2014 (14/1) Fig. 2. Morphological and immunohistochemical characteristics of the tumour. 2A, Tissue structure of the recurrent tumour. Haematoxylin-eosin, original magnification (OM) 100x; 2B, Intense expression of cytokeratin (CK) 7. Immunoperoxidase (IP), anti-CK7, OM 100x; 2C, Low proliferation fraction by Ki-67 in the initial neurosurgical operation material. IP, anti-Ki-67, OM 400x; 2D, Increased proliferation fraction in the recurrent tumour. IP, anti-Ki-67, OM 400x; 2E, Expression of TTF-1 in the initial neurosurgical material. IP, anti-TTF-1, OM 100x; 2F, Expression of TTF-1 in the recurrent tumour. IP, anti-TTF-1, OM 100x. Note the loss of architecture as well as increased nuclear polymorphism. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Acta Chirurgica Latviensis de Gruyter

Prolonged Survival After Neurosurgical Resection of Lung Cancer Metastasis

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Abstract

10.2478/chilat-2014-0106 ACTA CHIRURGICA LATVIENSIS • 2014 (14/1) CASE REPORT Prolonged Survival after Neurosurgical Resection of Lung Cancer Metastasis Gvido Janis Bergs*, Raimonds Bricis**, Arvids Jakovlevs*, Andrejs Vanags*, Ilze Strumfa* *Riga Stradins University, Latvia **Pauls Stradins Clinical University Hospital, Latvia SUMMARY Metastatic tumours in the brain occur more frequently than primary neoplasms. Despite the generally dismal prognosis, neurosurgical resection is indicated in certain patients and can yield prolonged survival. Here we describe an 82-year-old male with a history of neurosurgical resection of a single brain metastasis 6 years ago. Tumour immunophenotype disclosed lung adenocarcinoma with low proliferation fraction. However, the primary tumour remained occult then. At present, 3 new brain metastases were identified by computed tomography. Repeated resection was performed in 2 stages, resulting in removal of 2 metastases. Lung mass was now evident as well. The final diagnosis was lung adenocarcinoma with metachronous brain metastases, stage IV. In conclusion, prolonged survival, in this case 6 years, can be reached even in patients with metastatic cancer by successful selective application of neurosurgical treatment. The biological properties of the tumour including low proliferation also contributed to longer survival and demonstrated surgery as a successful treatment option. Key words: brain metastasis, neurosurgical resection, lung cancer, prolonged survival AIM OF THE DEMONSTRATION in the basal part of temporal lobe, measuring 3 mm. The In order to broaden the awareness of up-to-dated chest CT showed pathologic mass in right upper pulmonary neurosurgical treatment possibilities, here we report lobe, measuring 3.4x2.8 cm (Fig. 1B). Craniotomy was a well-documented case of prolonged survival due to performed in 2 steps. At first, left frontal bone craniotomy neurosurgical resection of brain metastasis in a patient provided access for resection of metastasis from frontal lobe with stage IV lung cancer. using neuronavigation. The second step included resection of parietal lobe metastasis, using neuronavigation from CASE REPORT different approach. The first step lasted 70 minutes, the An 82-year-old male was transferred to a clinical second – 115 minutes. Metastasis in temporal lobe was university hospital for elective brain metastasis resection. considered not accessible. The post-operative period was The patient complained of weakness in the right hand smooth. The histological examination of surgical material and leg as well as tightness in left side of face during the showed high-grade adenocarcinoma (Fig. 2A) expressing previous 8 months. Ten days before the admission, the the following immunohistochemistry (IHC) markers: patient felt dizzy and collapsed. He was admitted to a cytokeratins CK7 (Fig. 2B) and CKAE 1/3 as well as TTF-1, regional hospital. Computed tomography (CT) of the brain diagnostic of primary lung cancer. Six years ago histological revealed a mass lesion in left parietal lobe (Fig. 1A) thus examination of metastasis from right frontal lobe showed the patient was transferred for neurosurgical treatment. intermediate-grade papillary adenocarcinoma expressing He had a history of neurosurgical resection of a single the same IHC markers. The proliferation fraction of cancer brain metastasis in right frontal lobe 6 years ago. Tumour was 9.6% (Fig. 2C) in the first event, increased now to immunophenotype yielded lung adenocarcinoma with 36.7% (Fig. 2D). Thus, the cancer has transformed to low proliferation fraction. However, the primary tumour higher grade and significantly higher proliferation fraction. remained occult then as the chest CT was negative at that The higher grade was characterised by increased nuclear time. The medical history included also brain infarction polymorphism and by loss of papillary architecture (Fig. in the left middle cerebral artery basin 6 years ago and 2E) resulting in solid sheets of neoplastic cells (Fig. 2F). moderate primary arterial hypertension. The final diagnosis was lung adenocarcinoma with At present, the general condition was estimated as average. metachronous brain metastases, stage IV. The patient was The Glasgow coma scale score was 15. Neurological transferred back to regional hospital for further recovery. Oncologist council recommended symptomatic therapy examination revealed lower reflexes and positive Babinski’s sign on the right side. The arterial pressure under the guidance of family doctor. was 150/85 mmHg, the heart rate – 74 times per minute. Breathing sounds were normal having the frequency of 17 DISCUSSION times per minute. Both primary and metastatic tumours can affect the brain. Brain metastases outnumber primary neoplasms The contrast-enhanced CT of head and brain showed 3 mass lesions in the left hemisphere: in parietal lobe, by at least 10 to 1, and they occur in 20% to 40% of measuring 2x1.5 cm; in frontal lobe, measuring 5 mm and cancer patients. About 80% of metastases are located in 32 ACTA CHIRURGICA LATVIENSIS • 2014 (14/1) the cerebral hemispheres, 15% in the cerebellum, and 3. El Kamar FG, Posner JB. Brain metastases // Semin 5% in the brainstem. In a retrospective neurosurgical Neurol, 2004; 24:347 – 362 review, 45.6% of the patients had solitary brain metastasis 4. Fujimaki T. Surgical treatment of brain metastasis // without other systemic metastases, 26.5% had single Int J Clin Oncol, 2005; 10:74 – 80 brain metastasis along with other metastases, and the rest 5. Kalkanis SN, Kondziolka D, Gaspar LE, Burri SH, had two or more brain metastases. The most common Asher AL, Cobbs CS, Ammirati M, Robinson PD, primary cancer metastasizing to the brain is lung cancer Andrews DW, Loeffler JS, McDermott M, Mehta MP, that is responsible for 50% of all metastasis (Patchell, Mikkelsen T, Olson JJ, Paleologos NA, Patchell RA, 2003; El Kamar and Posner; 2004; Stark et al., 2011). Ryken TC, Linskey ME. The role of surgical resection Neurosurgical resection is recommended for patients with in the management of newly diagnosed brain a single accessible brain metastasis, especially when the metastases: a systematic review and evidence-based tumour size is large causing a considerable mass effect clinical practice guideline // J Neurooncol, 2010; or obstructive hydrocephalus. Surgery is also favoured 96:33 – 43 in patients with good performance status, who are 6. Kanou T, Okami J, Tokunaga T, Fujiwara A, Ishida functionally independent and in whom systemic disease D, Kuno H, Higashiyama M. Prognosis associated is limited or absent and for patients with radioresistant with the surgery for non-small cell lung cancer and primary tumour (Kalkanis et al., 2010). Multiple brain synchronous brain metastasis // Surg Today, 2014; metastases in most cases represent a contraindication for 44:1321 – 1327 neurosurgical treatment and resection is recommended 7. Lutterbach J, Bartelt S, Ostertag C. Long-term survival only for the dominant lesion (Paek et al., 2005). Multiple in patients with brain metastases // J Cancer Res Clin metastases can be handled in a single operation if they are Oncol, 2002; 128:417 – 425 located in the same hemisphere and are close to each other 8. Nussbaum ES, Djalilian HR, Cho KH, Hall WA. Brain (Fujimaki, 2005). Recurrent brain metastases develop in metastases. Histology, multiplicity, surgery, and 31 – 48% of neurosurgically treated patients, the median survival // Cancer, 1996; 78:1781 – 1788 survival is 4 months and 2-year survival is less than 6% 9. Paek SH, Audu PB, Sperling MR, Cho J, Andrews (Bindal et al., 1992; Nussbaum et al., 1996; Lutterbach et DW. Reevaluation of surgery for the treatment al., 2002). Despite the generally short survival of patients of brain metastases: review of 208 patients with affected by brain metastases of lung cancer (D’Antonio single or multiple brain metastases treated at one et al., 2014), longer survival has been reported as well institution with modern neurosurgical techniques // (Kanou et al., 2014). Neurosurgery, 2005; 56:1021 – 1034 The known prognostic factors for prolonged survival after 10. Patchell RA. The management of brain metastases // surgery in patients with non-small cell lung cancer and Cancer Treat Rev, 2003; 29:533 – 540 synchronous brain metastasis include small size of primary 11. Sica G, Yoshizawa A, Sima CS, Azzoli CG, Downey RJ, tumour and lack of lymph node involvement (Kanou et Rusch VW, Travis WD, Moreira AL. A grading system al., 2014). As the primary cancer in our patient remained of lung adenocarcinomas based on histologic pattern occult by CT, such characteristics can be hypothetically is predictive of disease recurrence in stage I tumors // assumed. In addition, the presented case was characterised Am J Surg Pathol, 2010; 34:1155 – 1162 also by initially low proliferation fraction that could 12. Stark AM, Stohring C, Hedderich J, Held-Feindt J, supposed to be associated with limited tumour spread. Mehdorn HM. Surgical treatment for brain metastases: However, conversion to high-grade (Sica et al., 2010) Prognostic factors and survival in 309 patients with adenocarcinoma with notably higher proliferation fraction regard to patient age // J Clin Neurosci, 2011; 18:34 – 38 followed. In conclusion, here we show a patient benefitting from prolonged survival of 6 years after successful neurosurgical Address resection of solitary lung cancer metastasis. The biological Ilze Strumfa properties of the tumour including low proliferation at the Department of Pathology, Riga Stradins University Dzirciema Street 16, LV-1007, Riga, Latvia first occurrence could contribute to longer survival and demonstrated surgery as a successful treatment option. E-mail: Ilze.Strumfa@rsu.lv The case is also notable for successful application of IHC detecting the tumour origin before it was radiologically visible. Conflict of interest: None REFERENCES 1. Bindal RK, Sawaya R, Lee JJ. Surgical treatment of multiple brain metastases // J Neurosurg, 1993; 79:210 – 216 2. D’Antonio C, Passaro A, Gori B, del Signore E, Migliorino MR, Ricciardi S, Fulvi A, de Marinis F. Bone and brain metastasis in lung cancer: recent Fig. 1. Computed tomography (CT) findings. 1A, advances in therapeutic strategies // Ther Adv Med Brain CT showing mass lesion in the left parietal Oncol, 2014; 6:101 – 114 lobe. 1B, Chest CT revealing a pathological mass in the right upper lobe. 33 ACTA CHIRURGICA LATVIENSIS • 2014 (14/1) Fig. 2. Morphological and immunohistochemical characteristics of the tumour. 2A, Tissue structure of the recurrent tumour. Haematoxylin-eosin, original magnification (OM) 100x; 2B, Intense expression of cytokeratin (CK) 7. Immunoperoxidase (IP), anti-CK7, OM 100x; 2C, Low proliferation fraction by Ki-67 in the initial neurosurgical operation material. IP, anti-Ki-67, OM 400x; 2D, Increased proliferation fraction in the recurrent tumour. IP, anti-Ki-67, OM 400x; 2E, Expression of TTF-1 in the initial neurosurgical material. IP, anti-TTF-1, OM 100x; 2F, Expression of TTF-1 in the recurrent tumour. IP, anti-TTF-1, OM 100x. Note the loss of architecture as well as increased nuclear polymorphism.

Journal

Acta Chirurgica Latviensisde Gruyter

Published: Nov 24, 2014

Keywords: Medicine; Clinical Medicine; Surgery; Surgery, other

References