Long-Term Survival After Brain Metastasis From Lung Cancer

DEBA P. SARMA, MD, AND THOMAS G. WEILBAECHER, MD

A case is reported of prolonged survival after lobectomy for large cell undifferentiated carcinoma of the lung and resection of metastatic carcinoma of the brain. The patient had survived 11 years 5 months after lung resection and 10 years 4 months after excision of brain metastasis. A review of the reports of another 12 patients who survived 5 years or longer after craniotomy, shows that the surgical excision of a single metastatic lesion of the brain with or without postoperative irradiation offers the best hope for prolonged survival.

Cancer 58:1366-1370, 1986.

HE PROGNOSIS OF PATIENTS with brain metastasis T from lung cancer is considered grave. The median survival ofthese patients, if not treated, is about 1 month, and with the use of steroids, about 2 months.' Lung cancer spreads to the brain usually via a vascular route, leading to multiple metastases. In about one-third of the cases, however, brain metastasis is a single lesion.2 In some se- lective cases where the primary lung tumor is controlled by proper therapy and there is no other systemic metas- tases, the excision of a single cerebral metastasis may pro- vide a hope for a long-term survival.

We report a case of prolonged survival of more than 10 years after excision of a metastatic carcinoma to the brain from a primary lung cancer. We also review another I2 reported cases of prolonged survivals of 5 to I6 years after craniotomy that we found in the English literature.

Case Report

A 57-year-old white man was admitted on July 3, 1979 in an unresponsive state with a rectal temperature of 107.2"F and a blood pressure of 5O/O mmHg. A clinical diagnosis of heat stroke was made.

On January 3 I , 1968, more than 1 1 years previously, the patient had undergone right middle and lower lobectomy of lung for an undifferentiated large cell carcinoma (Fig. 1) . The 5 X 5 cm tumor had involved both lobes and had metastasized to several bronchial lymph nodes (Fig. 2). There was no further therapy.

Eight months later the patient was diagnosed to have a met- astatic lesion in the right parietal lobe of the cerebrum. On Oc- tober 10, 1968, the patient underwent a craniotomy. The excised 2.5-cm tumor showed metastatic carcinoma (Figs. 3 and 4) sim-

From the Department of Pathology, Veterans Administration Medical Center and Louisiana State University Medical School, New Orleans, Louisiana.

Address for reprints: Deba Sarma, MD, 1601 Perdido Street, New Orleans, LA 70 146.

Accepted for publication January 9, 1986.

ilar to that seen in the lung. No additional therapy was given. The patient made a spectacular recovery from surgery. There was no significant neurologic deficit; however, he had developed occasional convulsive seizures which were well controlled by Dilantin (Parke-Davis), phenobarbital, and Valium (Roche).

There was no evidence of any recurrent tumor until 10 years later in November 1978, when chest x-ray findings revealed a possible neoplasm in the upper right lung. The patient underwent a thoracotomy and wedge resection of the right upper lobe tumor (2 cm in diameter). There were no grossly involved lymph nodes. Microscopically, the tumor was a large cell undifferentiated car- cinoma. In view of the excellent clinical course over the last 10 years, no further therapy was suggested.

Eleven hours after admission with hyperthermia, the patient died on July 4, 1979. He survived 11 years 5 months after re- section of the lung tumor and 10 years 4 months after excision of the metastatic brain tumor. At autopsy, recurrent carcinoma was noted in the right upper lobe with invasion into anterior chest wall. Metastatic tumor was noted in the mediastinal and the left cervical lymph nodes. There was no gross or microscopic tumor in the brain.

Discussion

Brain metastasis is a grave complication of lung cancer. Frequency of lung cancer metastasizing to brain varies from 16% to 65% in neurosurgical literature and from 17% to 55% in autopsy series2 Rarely does an untreated patient survive more than 3 months after the onset of cerebral symptoms.2 All forms of therapy available to these patients are considered palliative, including corticoste- roids, irradiation, surgery, and chemotherapy. Neurologic deficits can be improved, but rarely does the patient sur- vive more than 6 months3 A considerably improved me- dian survival of 14 months has been reported recently by Sundaresan et al.,4 with excision of the metastatic lesion of brain followed by irradiation (in 29 patients). They have noted the following favorable prognostic variables: (1 ) absence of local or systemic disease at time of crani-

1366

FIG. 1. Section from the resected lung showing undifferentiated large cell carcinoma infiltrating the bronchial submucosa (H & E, X80).

FIG. 2. Bronchial lymph node containing metastatic carcinoma (H & E, XSO).

FIG. 3. Resected brain lesion showing metastatic carcinoma (H & E, X80).

FIG. 4. Higher magnification showing large undifferentiated neoplasic cells with pleomorphic hyperchromatic nuclei and somewhat clear cytoplasm (H & E, X180).

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1370 CANCER September 15 1986 Vol. 58

otomy; (2) aggressive treatment of primary tumor; and ( 3 ) metachronous onset of brain metastases.

A review of the long-term survivors of lung cancer with brain metastasis (Table 1) shows that most of the patients were men between 40 and 60 years of age with a non-oat cell carcinoma of lung that was treated mostly by surgical exc i~ ion .~ - ’~ The metastatic tumor in the brain most commonly was a single nodule in the parietal lobe. The brain tumor was surgically removed followed by irradia- tion to brain in about 50% of the cases. A postcraniotomy survival of 5 to 16 years was reported.

In a selected number of patients with lung cancer with single brain metastasis, the only hope for a long-term sur- vival appears to be aggressive surgical excision of the met- astatic tumor with or without postoperative irradiation. The primary lung cancer should be under control by sur- gery with or without radiation. Before craniotomy and excision of the single metastasis, proper studies must ex- clude any other detectable metastases.

REFERENCES

I . Posner JB. Management of central nervous system metastases.

2. MacGee EE. Surgical treatment of cerebral metastases from lung Semin Oncol 1977; 431-91.

cancer: The effect of quality and duration of survival. J Neurosurg 197 I ; 35:416-420.

3. Robin E, Bitran JD, Golomb HM el al. Prognostic factors in patients with non-small cell bronchogenic carcinoma and brain metastases. Cancer 1982; 49: I9 16-19 19.

4. Sundaresan N, Galicich JH, Beattie EJ. Surgical treatment ofbrain metastases from lung cancer. J Neurosurg 1983; 58:666-67 1.

5. Fried BM, Buckley RC. Primary carcinoma of the lungs: IV. In- tracranial metastases. Arch Puthol 1930; 9:483-527.

6. Bakay L. Results of surgical treatment of intracranial metastasis from pulmonary cancer: Report of a case with five-year survival. J Neu- rosurg 1958; 15:338-341.

7. Russel DS, Rubinstein LJ. Pathology of Tumours of the Nervous System. London: Edward Arnold Publishers, 1959; 219.

8. Simionescu MD. Metastatic tumors of the brain: A follow-up study of 195 patients with neurosurgical considerations. JNeurosurg 1960; 17:

9. Raskind R, Weiss SR, Wermuth RE. Single metastatic brain tumors: Treatment and follow-up in 4 1 cases. A m Surg 1969; 355 10-5 15.

10. Hendricks GL, Barnes WT, Hood HL. Seven-year “cure” of lung cancer with metastasis to the brain. JAMA 1972; 220:127.

1 1. Modesti LM, Feldman RA. Solitary cerebral metastasis from pul- monary cancer: Prolonged survival after surgery. JAMA 1975; 23 l : 1064.

12. Mosberg WH. Twelve-year “cure” of lung cancer with metastasis to the brain. JAMA 1976; 235:2745-2746.

13. Tarnoff JF, Calinog TA, Byla JG. Prolonged survival following cerebral metastasis from pulmonary cancer. J Thoruc Curdiovasc Surg 1976; 72:933-937.

14. Salerno TA, Munro DD, Little JR. Surgical treatment of bron- chogenic carcinoma with a brain metastasis. J Neurosurg 1978; 48:350- 354.

361-373.

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