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Surgical Treatment of Single Pontomedullary Junction Metastasis from Lung Cancer

Surgical Treatment of Single Pontomedullary Junction Metastasis from Lung Cancer Hindawi Case Reports in Oncological Medicine Volume 2022, Article ID 4041506, 3 pages https://doi.org/10.1155/2022/4041506 Case Report Surgical Treatment of Single Pontomedullary Junction Metastasis from Lung Cancer 1 2 1 3 Paolo Missori , Simone Peschillo, Angela Ambrosone, Antonio Currà, and Sergio Paolini Department of Human Neurosciences, Neurosurgery, Policlinico Umberto I, “Sapienza” University of Rome, Italy Department of Neurosurgery, University of Catania, Catania, Italy Department of Medical-Surgical Sciences and Biotechnologies, Academic Neurology Unit, Ospedale A. Fiorini, Terracina, LT, “Sapienza” University of Rome, Polo Pontino, Italy IRCCS Neuromed-Pozzilli, “Sapienza” University of Rome, Polo Pontino, Italy Correspondence should be addressed to Paolo Missori; missorp@yahoo.com Received 14 February 2022; Accepted 13 May 2022; Published 31 May 2022 Academic Editor: Mauro Cives Copyright © 2022 Paolo Missori et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. When lung cancer develops a solitary metastasis at the pontomedullary junction, due to surgical risk, the current oncologic treatment is radiosurgery and chemotherapy. Case Description. We describe a patient with a single intrinsic metastasis at the pons and medulla. Removal was successful, without complication. Conclusion. Surgery can provide excellent results, and in selected patients, it should be considered a first-line treatment in experienced hands. 1. Introduction 2. Case Presentation Solitary metastases from lung cancer are very rarely found in A 63-year-old female with a history of smoking was admit- the medulla oblongata and pons. In this location, autopsy ted to the hospital due to double vision and impaired bal- studies have shown single or multiple metastases, which ance, 2 weeks prior to our examination. On examination, account for 0.06 to 7%, respectively [1]. Currently, the sug- she displayed severe, unsteady gait, left cranial nerve VI gested oncologic treatment for this type of metastasis is palsy, and reduced sensitivity to light touch and a pinprick radiosurgery and chemotherapeutic treatment [2]. Surgery in the right arm. CT and MR imaging studies showed a sin- has only been performed in exceptional cases. One study gle 13 mm, roundish, intrinsic lesion at the pontomedullary reported a subtotal excision of an intrinsic metastatic adeno- junction (Figure 1). A chest X-ray showed a lesion in the left carcinoma at the pontomedullary junction [3]. Two other lung. A full-body CT scan excluded any other tumor loca- studies have described surgical treatments for patients with tion. Due to the rapid worsening of symptoms, surgical lateral pontine and medulla oblongata metastases from ade- treatment was recommended. Through a suboccipital crani- nocarcinoma [4, 5]. Here, we present the surgical removal of otomy and telovelar approach, we observed that the lesion an intrinsic pontomedullary junction metastasis from lung slightly emerged from the IV ventricle floor. The lesion cancer and its clinical course. was completely removed (Figure 2). The histological diagno- sis was adenocarcinoma. The postoperative course was uneventful, and the patient also underwent removal of the lung tumor. Due to T3 N1 M1b staging, a course of radiation and chemotherapeutic agents were administered. At an 8- 2 Case Reports in Oncological Medicine (a) (b) Figure 1: (a) Preoperative contrast-enhanced MRI shows a 13 mm intrinsic, roundish lesion in the posterior pontomedullary junction. (b) The floor of the inferior IV ventricle is slightly raised, and the tumor slightly protrudes from it. (a) (b) Figure 2: (a) Postoperative contrast-enhanced MRI confirms that the metastasis was totally removed. (b) The remaining medulla and pons tissues have filled the space, except for a very thin gap. Case Reports in Oncological Medicine 3 month follow-up, the neurological examination showed per- sistent left VI nerve palsy and slight gait unsteadiness. 3. Discussion Gamma knife radiosurgery is widely considered the best option for managing intrinsic brainstem metastases. How- ever, adverse radiation effects are a major concern. Although this surgery is the treatment of choice for patients with mul- tiple secondary brain lesions, surgery can be considered for patients with a single intrinsic brainstem lesion. Three man- datory points must be assessed for this treatment: first, the primary tumor must be considered entirely removable with the most suitable treatment; second, no other secondary localizations should be detected in the whole-body CT stud- ies; and third, come out of the intrinsic brainstem metastasis. When pontomedullary junction metastases meet these cri- teria, surgical removal may be feasible in selected patients, without complications. Finally, the surgeon must be confi- dent with the surgical approach, which takes place in a cis- ternal subarachnoid corridor; this is the last, but not least, criterion that is essential for performing a surgical treatment in patients with cancer. Data Availability Raw data were generated at the Policlinico Umberto I, “Sapienza” University of Rome Hospital. Further enquiries can be directed to the corresponding author. Conflicts of Interest The authors declare that they have no competing interest. References [1] Y. Tsukada, A. Fouad, J. W. Pickren, and W. W. Lane, “Central nervous system metastasis from breast carcinoma. Autopsy study,” Cancer, vol. 52, no. 12, pp. 2349–2354, 1983. [2] T. Kawabe, M. Yamamoto, Y. Sato et al., “Gamma knife surgery for patients with brainstem metastases,” Journal of Neurosur- gery, vol. 117, Special_Suppl, pp. 23–30, 2012. [3] R. J. Hacker and J. L. Fox, “Surgical treatment of brain stem car- cinoma,” Neurosurgery, vol. 6, no. 4, pp. 430–432, 1980. [4] W. T. Couldwell and C. Shelton, “Transtemporal approach to the removal of a lateral pontine tumor,” Neurosurgical Focus, vol. 36, v1supplement, p. 1, 2014. [5] E. Suero Molina and W. Stummer, “Where and when to cut? Fluorescein guidance for brain stem and spinal cord tumor sur- gery—technical note,” Operative Neurosurgery, vol. 15, no. 3, pp. 325–331, 2018. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Case Reports in Oncological Medicine Hindawi Publishing Corporation

Surgical Treatment of Single Pontomedullary Junction Metastasis from Lung Cancer

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Hindawi Publishing Corporation
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Copyright © 2022 Paolo Missori et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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2090-6706
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2090-6714
DOI
10.1155/2022/4041506
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Abstract

Hindawi Case Reports in Oncological Medicine Volume 2022, Article ID 4041506, 3 pages https://doi.org/10.1155/2022/4041506 Case Report Surgical Treatment of Single Pontomedullary Junction Metastasis from Lung Cancer 1 2 1 3 Paolo Missori , Simone Peschillo, Angela Ambrosone, Antonio Currà, and Sergio Paolini Department of Human Neurosciences, Neurosurgery, Policlinico Umberto I, “Sapienza” University of Rome, Italy Department of Neurosurgery, University of Catania, Catania, Italy Department of Medical-Surgical Sciences and Biotechnologies, Academic Neurology Unit, Ospedale A. Fiorini, Terracina, LT, “Sapienza” University of Rome, Polo Pontino, Italy IRCCS Neuromed-Pozzilli, “Sapienza” University of Rome, Polo Pontino, Italy Correspondence should be addressed to Paolo Missori; missorp@yahoo.com Received 14 February 2022; Accepted 13 May 2022; Published 31 May 2022 Academic Editor: Mauro Cives Copyright © 2022 Paolo Missori et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. When lung cancer develops a solitary metastasis at the pontomedullary junction, due to surgical risk, the current oncologic treatment is radiosurgery and chemotherapy. Case Description. We describe a patient with a single intrinsic metastasis at the pons and medulla. Removal was successful, without complication. Conclusion. Surgery can provide excellent results, and in selected patients, it should be considered a first-line treatment in experienced hands. 1. Introduction 2. Case Presentation Solitary metastases from lung cancer are very rarely found in A 63-year-old female with a history of smoking was admit- the medulla oblongata and pons. In this location, autopsy ted to the hospital due to double vision and impaired bal- studies have shown single or multiple metastases, which ance, 2 weeks prior to our examination. On examination, account for 0.06 to 7%, respectively [1]. Currently, the sug- she displayed severe, unsteady gait, left cranial nerve VI gested oncologic treatment for this type of metastasis is palsy, and reduced sensitivity to light touch and a pinprick radiosurgery and chemotherapeutic treatment [2]. Surgery in the right arm. CT and MR imaging studies showed a sin- has only been performed in exceptional cases. One study gle 13 mm, roundish, intrinsic lesion at the pontomedullary reported a subtotal excision of an intrinsic metastatic adeno- junction (Figure 1). A chest X-ray showed a lesion in the left carcinoma at the pontomedullary junction [3]. Two other lung. A full-body CT scan excluded any other tumor loca- studies have described surgical treatments for patients with tion. Due to the rapid worsening of symptoms, surgical lateral pontine and medulla oblongata metastases from ade- treatment was recommended. Through a suboccipital crani- nocarcinoma [4, 5]. Here, we present the surgical removal of otomy and telovelar approach, we observed that the lesion an intrinsic pontomedullary junction metastasis from lung slightly emerged from the IV ventricle floor. The lesion cancer and its clinical course. was completely removed (Figure 2). The histological diagno- sis was adenocarcinoma. The postoperative course was uneventful, and the patient also underwent removal of the lung tumor. Due to T3 N1 M1b staging, a course of radiation and chemotherapeutic agents were administered. At an 8- 2 Case Reports in Oncological Medicine (a) (b) Figure 1: (a) Preoperative contrast-enhanced MRI shows a 13 mm intrinsic, roundish lesion in the posterior pontomedullary junction. (b) The floor of the inferior IV ventricle is slightly raised, and the tumor slightly protrudes from it. (a) (b) Figure 2: (a) Postoperative contrast-enhanced MRI confirms that the metastasis was totally removed. (b) The remaining medulla and pons tissues have filled the space, except for a very thin gap. Case Reports in Oncological Medicine 3 month follow-up, the neurological examination showed per- sistent left VI nerve palsy and slight gait unsteadiness. 3. Discussion Gamma knife radiosurgery is widely considered the best option for managing intrinsic brainstem metastases. How- ever, adverse radiation effects are a major concern. Although this surgery is the treatment of choice for patients with mul- tiple secondary brain lesions, surgery can be considered for patients with a single intrinsic brainstem lesion. Three man- datory points must be assessed for this treatment: first, the primary tumor must be considered entirely removable with the most suitable treatment; second, no other secondary localizations should be detected in the whole-body CT stud- ies; and third, come out of the intrinsic brainstem metastasis. When pontomedullary junction metastases meet these cri- teria, surgical removal may be feasible in selected patients, without complications. Finally, the surgeon must be confi- dent with the surgical approach, which takes place in a cis- ternal subarachnoid corridor; this is the last, but not least, criterion that is essential for performing a surgical treatment in patients with cancer. Data Availability Raw data were generated at the Policlinico Umberto I, “Sapienza” University of Rome Hospital. Further enquiries can be directed to the corresponding author. Conflicts of Interest The authors declare that they have no competing interest. References [1] Y. Tsukada, A. Fouad, J. W. Pickren, and W. W. Lane, “Central nervous system metastasis from breast carcinoma. Autopsy study,” Cancer, vol. 52, no. 12, pp. 2349–2354, 1983. [2] T. Kawabe, M. Yamamoto, Y. Sato et al., “Gamma knife surgery for patients with brainstem metastases,” Journal of Neurosur- gery, vol. 117, Special_Suppl, pp. 23–30, 2012. [3] R. J. Hacker and J. L. Fox, “Surgical treatment of brain stem car- cinoma,” Neurosurgery, vol. 6, no. 4, pp. 430–432, 1980. [4] W. T. Couldwell and C. Shelton, “Transtemporal approach to the removal of a lateral pontine tumor,” Neurosurgical Focus, vol. 36, v1supplement, p. 1, 2014. [5] E. Suero Molina and W. Stummer, “Where and when to cut? Fluorescein guidance for brain stem and spinal cord tumor sur- gery—technical note,” Operative Neurosurgery, vol. 15, no. 3, pp. 325–331, 2018.

Journal

Case Reports in Oncological MedicineHindawi Publishing Corporation

Published: May 31, 2022

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