Complete resection of non-small-cell lung cancer and oligo-metastatic brain disease

BACKGROUND: Non-small-cell lung cancer is a leading cause of cancer morbidity and mortality in Australia. Brain metastases are common, and rapidly fatal if untreated. Optimal management consists of resection and whole brain irradiation. However, there is a paucity of local data documenting survival after such treatment. METHODS: Medical records for all patients who underwent complete resection of non-small-cell lung cancer at one institution between January 1999 and December 2003 were reviewed in order to determine survival after initial surgery. The survival of all patients was compared with patients who underwent resection of synchronous or metachronous brain metastases and whole brain irradiation as part of their lung cancer management. RESULTS: Between 1 January 1999 and 31 December 2003, 170 patients underwent complete resection of non-small-cell lung cancer by a thoracic surgeon. Resection of synchronous or metachronous brain metastases followed by whole brain irradiation was also carried out on 15 of these patients. Complete cerebral resection was achieved in 12 cases. The overall 5-year survival after attempted curative resection of brain metastases and successful complete resection was 60% and 70%, respectively. The survival of patients with both cerebral metastasectomy and lung cancer resection approximated that of the cohort of patients that only required complete resection of their lung cancer. CONCLUSIONS: Control of local disease at each site and long-term survival after lung resection and resection of either synchronous or metachronous brain METASTASIS and whole brain irradiation is readily achievable. We believe this should continue as the standard of care for this presentation.     

Clinical study of brain metastasis of renal cell carcinoma.

OBJECTIVES: To evaluate the natural history and the efficacy of treatments for renal cell carcinoma (RCC) with brain metastasis, we reviewed 18 patients with this disease. METHODS: Out of 325 cases with RCC treated at Osaka University Hospital from 1957 to 1993, 18 (5.5%, male:female ratio 16:2) cases developed brain metastases. Median follow-up was 44 months after the initial treatment of the primary lesion. Twelve patients had surgical resection of brain metastases (surgical group), and 7 of them received adjuvant radiotherapy. Six patients with poor performance status were treated with supportive therapy alone (nonsurgical group). RESULTS: Of 18 RCC patients with brain metastasis, 16 were male and 2 female. All brain metastases except for 1 case were symptomatic. Median interval between the initial treatment of the primary lesion and the diagnosis of brain metastasis was 19 months. The most frequent metastatic site prior to brain was the lung, which was detected in 7 cases (38.9%). Median survival of the entire group, measured from the onset of brain metastasis, was 9.5 months. One-year survival rate after the diagnosis of brain metastasis was 43.2% (64.8% in surgical group, 0% in nonsurgical group), 3-year 18.5% and 5-year 0%. Among 109 metastatic RCC, 14 patients were treated by lymphokine-activated killer (LAK) therapy. Out of 14 metastatic RCC patients treated by LAK therapy, 3 (21.4%) developed brain metastases. On the other hand, out of 95 metastatic RCC patients without LAK therapy, 15 (15.8%) had brain metastases. There was no significant difference in the rate of brain metastases between these two groups. CONCLUSION: There was a trend for prognosis of the surgical group to be better compared to that of the nonsurgical group, although it is not statistically significant. The optimum treatment for brain metastasis of RCC remains undefined, but our data suggested surgical resection in selected patients might contribute to prolonged survival of patients with brain metastasis. LAK therapy was not necessarily the risk factor of the brain metastasis.     

Does the surgical resection of a brain metastasis alter the planning and subsequent local control achieved with radiosurgery prescribed for recurrence at the operated site?

Multiple treatments may be used in the management of patients with brain metastases including surgical resection or radiosurgery. In order to determine whether initial surgical resection in any way prejudices the subsequent efficacy of radiosurgery for recurrence at the operated site, a retrospective review of patients undergoing radiosurgery at the time of relapse was undertaken. All patients had previously received whole brain irradiation as part of initial management. A comparison of radiosurgical planning technique was made for recurrent brain metastases occurring at sites of a previous surgical resection versus unresected recurrences. Although recurrences of tumour at a resected site were more likely to be treated radiosurgically using larger and multiple collimators, there was no significant difference in subsequent local control. Assuming that the recurrence of a brain metastasis at a previously resected site is considered treatable radiosurgically, subsequent local control is no different from that achieved in previously unresected recurrences.     

Utility of expanded anterior column resection versus decompression-alone for local control in the management of carcinomatous vertebral column metastases undergoing adjuvant stereotactic radiotherapy

Background ContextWith improvements in adjuvant radiotherapy and minimally invasive surgical techniques, separation surgery has become the default surgical intervention for spine metastases at many centers. However, it is unclear if there is clinical benefit from anterior column resection in addition to simple epidural debulking prior to stereotactic body radiotherapy (SBRT).PurposeTo examine the effect of anterior column debulking versus epidural disease resection alone in the local control of metastases to the bony spine.Study DesignRetrospective cohort study.Patient SampleNinety-seven patients who underwent open surgery followed by SBRT for spinal metastases at a single comprehensive cancer center.Outcome Measures: Local tumor recurrence following surgery and SBRT.MethodsData were collected regarding radiation dose, cancer histology, extent of anterior column resection, and recurrence. Tumor involvement was categorized using the International Spine Radiosurgery Consortium guidelines. Univariable analyses were conducted to determine predictors of local recurrence and time to local recurrence.Results: Among the 97 included patients, mean age was 60.5±11.4 years and 51% of patients were male. The most common primary tumor types were lung (20.6%), breast (17.5%), kidney (13.4%) and prostate (12.4%). Recurrence was seen in 17 patients (17.5%) and local control rates were: 85.5% (1-year), 81.1% (2-year), and 54.9% (5-year). Overall predictors of local recurrence were tumor pathology (p<.01; renal cell carcinoma and colorectal adenocarcinoma associated with poorest PFS) and undergoing anterior column debulking versus epidural decompression-alone (p=.03). Only tumor pathology predicted time to local recurrence (p<.01), though inspection of Kaplan-Meier functions showed superior long-term local control in patients with radiosensitive tumor pathologies, no previous irradiation of the metastasis, and who underwent anterior column resection versus epidural removal alone. Median time to recurrence was 288 days with 100% of lesions showing anterior column recurrence and recurrence in the epidural space.Conclusions: With the increasing shift towards surgery as a neoadjuvant to radiotherapy for patients with spinal column metastases, the role for surgical debulking has become less clear. In the present study, we find that anterior column debulking as opposed to epidural debulking-alone decreases the odds of local recurrence and improves long-term local control.     

根治性手术切除结直肠癌肺转移灶的临床疗效及预后影响因素分析

目的:探讨根治性手术切除结直肠癌肺转移灶的临床疗效及预后影响因素。方法:采用回顾性队列研究方法。收集2004年1月至2015年12月北京大学肿瘤医院收治的63例结直肠癌肺转移病人的临床病理资料;男35例,女28例;年龄为（57±12）岁。病人均行原发灶和结直肠癌肺转移灶根治性R 0切除术。观察指标：（1）诊...     

Postoperative intracranial seeding of craniopharyngioma. Three case reports and a review of the literature

Metastasis of craniopharyngioma is uncommon. Only 10 cases have been reported in the literature. In this report, we describe 3 patients who presented metastases following operative treatment of suprasellar craniopharyngioma. All 3 patients (ages: 32, 11, and 9 years) underwent radical excision of a supradiaphragmatic, retrochiasmatic craniopharyngioma by the right frontopterional approach. Resection was considered as total in all cases. All patients required hormone replacement therapy. Local recurrence was observed in only one case. Metastasis occurred along the surgical route in all three patients. The interval between surgery and metastasis was 5 and 3 years in the first two cases. The third patient presented two metastases: one in the temporal space at 3 years and another in the frontal space at 10 years. Repeat surgery was performed in 2 patients. The first case involved a lesion located in the right frontal space, and the second involved local recurrence and metastasis along the surgical route. The third patient was treated by puncture and radiation therapy for the temporal lesion and surveillance for the frontal lesions. No recurrence has been observed at 2 and 7 years after re-operation. Although rare, metastasis of craniopharyngioma has been reported up to 21 years after resection of the primary tumor. Metastasis often occurs along the surgical route, as in our 3 cases, but spreading to distant locations via cerebrospinal fluid has been observed. Regular follow-up is necessary, even after supposedly total resection.     

Results of the surgical treatment of metastatic brain tumors

Results of surgical treatment in 85 cases with metastatic brain tumors are reviewed. The lung was the most frequent site of primary lesion and the following sites were GI tract and the breast. Adequate treatment consisted of total removal of tumor, irradiation and/or chemotherapy were carried out in 51 cases. The remaining 34 cases had an unsuccessful treatment because of their poor physical condition. Mean survival time after adequate treatment was 8.75 months in the former group and 3.06 months in the latter group. Of 51 patients (86.3%) in the former group, 44 showed improvement of the neurological signs after treatment. In the latter group, only 14 patients (41.2%) revealed neurological improvement. Total removal of tumor was carried out in 55 of 85 cases. The one-month operative mortality for all patients was 19.2%. Postoperative one-year survival rate was 12.5% in 16 cases with multiple metastases and in 36 cases with single metastasis was 25.6%. Follow-up study of 77 cases showed 31.2% of survival rate in 6 months, 18.2% in one-year and 5.2% in two-years. Only four patients survived more than 3 years after treatment. The direct causes of death in cases of total removal were attributed in recurrence of primary lesion or remote metastases to other organs. This study revealed that the prognosis of the patient with metastatic brain tumor was influenced by existence of intracranial hypertension due to brain edema or metastatic tumor itself and metastases to other organs.(ABSTRACT TRUNCATED AT 250 WORDS)     

The neurosurgical management of brain metastasis from colorectal cancer: A report of three cases

We report herein three cases of brain metastasis from primary colorectal cancer in which the metastatic lesion was resected to effectively relieve neurological symptoms. Case 1 was a 61-year-old woman with a solitary brain metastasis from colorectal cancer and no other metastases; case 2 was a 59-year-old woman who died from liver metastasis 11 months after resection of the metastatic brain tumor; and case 3 was a 68-year-old woman with multiple metastases to the lungs and bones detected before the brain metastasis. According to 16 cases previously reported in the Japanese literature and our 3 cases, the interval between diagnosis of the primary cancer and discovery of brain metastasis was 23 months on average, while the median survival after the discovery of brain metastasis was 7 months. Brain metastases with liver and lung metastases were seen more frequently than brain metastases alone. In these three cases, chemotherapy appears to have been of no use in preventing recurrence. Thus, we believe neurosurgical management to be appropriate for a solitary lesion and that it should be actively pursued to prolong survival and improve quality of life.     

The role of postoperative radiotherapy after resection of single brain metastases

To assess the value of whole brain radiotherapy (WBRT) after complete resection of a single brain metastasis we reviewed the records of 98 patients who had elective craniotomy between 1978 and 1985. Seventy-nine patients received postoperative WBRT (Group A) and 19 patients no radiotherapy (RT) (Group B). Neurological relapse was designated as local (i.e., at the site of the original metastasis) or distant (i.e., elsewhere in the brain). Postoperative WBRT significantly prolonged the time to any neurological relapse (P = 0.034) with a 1-year recurrence rate of 22% in Group A and 46% in Group B patients; however, it did not specifically control either local or distant cerebral recurrence. Recurrence of metastatic brain disease was not affected by location of the original lesion; however, meningeal relapse occurred in 38% of cerebellar lesions, but only in 4.7% of supratentorial metastases (P = 0.003). The total radiation dose or fractionation scheme of RT did not affect survival nor time to neurological relapse. The median survival was 20.6 and 14.4 months for Groups A and B, respectively (not statistically different). Forty-eight percent of Group A and 47% of Group B patients survived for 1 year or longer; however, 11% of patients who had received RT and survived 1 year developed severe radiation-induced dementia. All patients with radiation-related cerebral damage received hypo-fractionated RT with high daily fractions as commonly designed for rapid palliation of macroscopic brain metastases.(ABSTRACT TRUNCATED AT 250 WORDS)     

Metastatic Bednar tumor (pigmented dermatofibrosarcoma protuberans) with fibrosarcomatous change: a case report

Bednar tumor (pigmented dermatofibrosarcoma protuberans) is a variant of dermatofibrosarcoma protuberans (DFSP) that constitutes 5% of all DFSP and has a very low rate of distant metastases. We encountered a rare case of Bednar tumor with multiple different distant metastases. A 51-year-old man, who had had a history of mass resection in his left shoulder 4 years previously, was referred to our institution, complaining of a recurrence of the shoulder mass. The histological diagnosis of primary tumor was Bednar tumor, and he underwent resectional surgery for the recurrent lesion. A second local relapse, lung metastasis, retroperitoneal metastasis, and metastasis to the sigmoid colon have occurred. The recurrence lesion and all metastatic lesions were resected surgically. The histological features of all specimens showed fibrosarcomatous change. Seven months after the last surgical resection, the tumor recurred and the patient died of multiple abdominal metastases 10 years after the first surgical treatment.     

Sclerosing Rhabdomyosarcoma: Report of a Case Arising in the Head and Neck of an Adult and Review of the Literature

Sclerosing rhabdomyosarcoma is a unique rhabdomyosarcoma variant, characterized by a prominent hyalinizing matrix. A notable pitfall is the potential for the unusual matrix and often pseudovascular growth pattern of this lesion to lead to confusion with other sarcoma types, including osteosarcoma, chondrosarcoma, and angiosarcoma. Here we report a case of sclerosing rhabdomyosarcoma arising in a 40-year old male. The tumor was centered in the pterygomaxillary fossa with extensive infiltration into adjacent structures. Fine needle aspiration yielded a preliminary diagnosis of high-grade pleomorphic undifferentiated sarcoma, for which he received neoadjuvant chemotherapy and surgical resection. Microscopic examination showed a malignant spindled to round cell neoplasm with prominent osteoid-like, hyaline stroma. Focal rhabdomyoblastic differentiation and diffuse immunoreactivity for desmin and myogenin aided in diagnosis. Nineteen months status post primary resection, the patient expired with multiple lung and bony metastases. Among 39 cases reported thus far (including the present case), there is a broad age range (0.3–79 years), with an average age at presentation of 27 years. The most commonly involved sites are the extremities (n = 19) and head and neck (n = 15). Most cases have been treated by resection, often combined with radiation and/or chemotherapy. Out of 31 cases with follow-up information provided, 6 patients developed local recurrence, 7 patients developed regional or distant metastasis, and 5 patients died of disease. Herein we discuss the ongoing controversy regarding how sclerosing rhabdomyosarcoma might best fit into existing rhabdomyosarcoma classification schemes, based upon current clinicopathologic and molecular genetic evidence.     

Treatment Strategies for Hepatic Metastases From Pancreatic Cancer in Patients Previously Treated With Radical Resection Combined With Intraoperative Radiation Therapy

Since 1984, we have performed extended radical resection combined with extended intraoperative radiation therapy (IORT) for pancreatic cancer. This approach has provided a dramatic improvement in long-term survival and control of local recurrence. Hepatic metastases, however, remain an unsolved problem. Among patients with this combined therapy, we found hepatic metastases in 8 of 22 patients postoperatively. Four of these 8 were considered candidates for further therapy and underwent treatment for their hepatic metastases, the other 4 had too extensive disease. Two patients with multiple hepatic metastases underwent percutaneous ethanol injection therapy and chemotherapy, but they died within a year. Two patients with a solitary hepatic metastases underwent hepatic resection. One patient died two years and six months after the first operation because of multiple metastases in the liver and both lungs, while the other patient is still alive over six years after the first operation with an excellent performance status. When a patient has no local recurrence and a solitary metastasis in the liver, surgical resection of the liver metastasis should be performed.     

Metastatic lung tumor from uterine leiomyosarcoma

We herein present 2 cases of metastatic lung tumor derived from uterine leiomyosarcoma. In the case 1, a 59-year-old woman was admitted to our hospital to examine abnormal shadow detected on chest X-ray. She had undergone hysterectomy and oophorectomy for uterine leiomyosarcoma 19 months previously. A round 3 cm mass in the right lung (S10) was seen on chest X-ray and computed tomography (CT). No other distant metastases or local recurrence were found, and the right lower lobectomy was perfomed under the clinical diagnosis of metastatic lung tumor. Postoperative pathologic examination revealed the tumor as a metastatic leiomyosarcoma. The patient recovered uneventfully, and there have been no signs of recurrence for 26 months after the pulmonary resection. In the case 2, a 58-year-old woman, who had undergone hysterectomy and oophorectomy for uterine leiomyosarcoma 7 months previously, was admitted to our hospital for further examination of pulmonary tumors on chest X-ray. Two tumors were recognized in the left lung (S8 and S10) on chest X-ray and CT. No other distant metastases or local recurrence were found, and the left lower lobectomy was performed under the clinical diagnosis of metastatic lung tumors. Pathological examinations revealed smooth muscle cells with nuclear pleomorphism and high mitotic indices. The tumors proved to be lung metastases derived from uterine leiomyosarcoma. Postoperative course was uneventful. However, brain metastasis was found 1 month after the pulmonary resection, and she underwent resection of brain metastasis. Two months after the brain metastasectomy, local recurrence of the brain tumor developed and re-resection followed by stereotactic radiotherapy was performed. Furthermore, intrapelvic recurrence was found 4 months after the pulmonary resection. Exploratory laparotomy revealed the tumor was unresectable, and she received 4 courses of chemotherapy (paclitaxel and carboplatin). For metastatic lung tumor from uterine leiomyosarcoma, surgery has been considered the best choice. However, for patients with uterine leiomyosarcoma who cannot be treated surgically because of multiple metastatic tumors or poor surgical risk chemotherapy (paclitaxel and carboplatin) or stereotactic radiotherapy can be strategies.     

Pulmonary resection for metastatic breast cancer.

Thirty-three patients treated primarily with surgical excision of pulmonary metastases from breast cancer were compared with 30 patients treated primarily with systemic chemohormonal therapy. Treatment for patients in the surgical group included pulmonary resection alone in 20, resection plus adjuvant systemic therapy in nine, and resection plus adjuvant radiation therapy in four. Treatment for patients in the medical group included systemic therapy alone in 22 and systemic therapy plus local radiation therapy in eight. Mean survival in the surgical group was significantly longer than that in the medical group, even when only those patients who manifested single pulmonary nodules were compared (58 months vs 34 months). The overall 5-year survival rate after treatment of lung metastasis was significantly greater for the surgical group than for the medical group (36% vs 11%). The results of this study indicate that surgical resection should be considered in patients with breast cancer who develop operable pulmonary metastases without evidence for concomitant extrapulmonary disease. In selected patients, such therapy may result in a survival benefit.     

Results of a phase II trial of the GliaSite radiation therapy system for the treatment of newly diagnosed, resected single brain metastases

OBJECT: The aim of this study was to evaluate the effectiveness of brachytherapy using the GliaSite Radiation Therapy System in patients with a newly diagnosed resected single brain metastasis. The primary end point of the study was local tumor control. The secondary end points included patient survival, distant brain recurrence, quality of life, and treatment toxicity. METHODS: The authors conducted a prospective multiinstitutional phase II study of GliaSite brachytherapy prescribed at a 60-Gy dose administered to a 1-cm depth after resection of a single brain metastasis. No whole-brain radiation therapy was given. Patients were assessed at 1 and 3 months after brachytherapy and every 3 months thereafter for up to 2 years. Seventy-one patients were enrolled at 13 centers. A GliaSite balloon catheter was implanted in 62 patients. Fifty-four patients received brachytherapy. The median patient age was 60 years. The most common tumor (54%) was non-small cell lung cancer. Fifty-seven percent of patients had brain metastasis only, whereas 43% had extracranial metastasis. The median final administered dose was 60 Gy. The magnetic resonance imaging--determined local control rate, based on several different methods, was 82 to 87%. Both the median patient survival time and the median duration of functional independence were 40 weeks. Among the 35 patients who died, the cause of death was neurological in 11%. Thirteen patients underwent reoperation for suspected tumor recurrence or radiation necrosis, and histological diagnoses included radiation necrosis without tumor (nine patients), radiation necrosis mixed with tumor (two patients), and tumor only (two patients). Extracranial metastasis, tumor size, and radiation necrosis were significant factors affecting patient survival. CONCLUSIONS: In patients with a resected single brain metastasis, GliaSite brachytherapy leads to a local control rate, median patient survival time, and duration of functional independence similar to those achieved with resection plus whole-brain radiation therapy.     

Brain tumors in infants and children--factors affecting prognosis, (Part-3). Mode of metastasis and prognosis in medulloblastoma

Brain tumors in infants and children are different from those in adults in type and location of tumor as well as accompanying complication. Given this fact, and the fact that these patients are under development, careful consideration is required for determination of treatment planning. Thus, we have investigated the curative results of brain tumors in infants and children and factors effecting prognosis. In this study, medulloblastoma which is one of the most malignant pediatric brain tumors was analyzed in 64 cases in light of mode of metastasis and prognosis. Among those cases, there were 23 cases which were diagnosed to have metastasis or infiltration of tumor from the original site of the fourth ventricle. As mode of the cerebrospinal fluid circulation, 6 intracerebral solitary metastasis, 1 entraspinal cord metastasis, 1 intraperitoneal metastasis via shunt and 7 generalized metastases involving bone in 5, lymphnodes in 2 and liver, spleen, kidney, lung and peintoneal cavity in 1 respectively. The survival rate in those 23 cases with tumor metastasis or infiltration was 63.6% in one year, 28.6% in two years and 11.8% in five years and the average survival year was 8.1 months in cases who died of these tumor metastasis. Six of them had tumor metastasis with in 6 months after the initial treatment(s).There was no significant correlations in rate or occurrence of tumor metastasis between group of total resection and of partial resection nor group of whole neuro-axis radiation and of local radiation.(ABSTRACT TRUNCATED AT 250 WORDS)     

The expanding role of neurosurgeons in the management of brain metastases

BACKGROUND: Brain metastases are the most common type of intracranial tumor. Until recently, whole brain fractionated radiation therapy (WBRT) was the mainstay of treatment, thereby confining the role of neurosurgeons to resection of an occasional solitary, accessible, and symptomatic brain metastasis. Median survival after surgery and radiation typically ranged from 5 to 11 months. METHODS: We analyzed various demographic incidence reports and our series of brain metastasis patients treated with radiosurgery. During a 15-year interval (1987-2002), radiosurgery was performed on 5,032 patients of whom 1,088 (21.6%) had metastatic brain tumors. RESULTS: In the United States, 266,820 to 533,640 new cases of brain metastases will be diagnosed in the year 2003. Evidence to date demonstrates that radiosurgery provides effective local tumor control for brain metastases. Important prognostic factors affecting patient survival include the absence of active systemic disease, the patient's preoperative performance status, age, and the number of metastases. Survival and local tumor control rates attained with radiosurgery are superior to those of either conventional surgery or WBRT. The morbidity associated with radiosurgery of brain metastasis is very low, and the mortality rate approaches zero. CONCLUSIONS: Compelling evidence indicates that radiosurgery is an effective neurosurgical management strategy for intracranial brain metastases. Quite often, favorable tumor control and survival can be achieved without WBRT. With radiosurgery as a therapeutic option, neurosurgeons now have a vastly expanded armamentarium for treatment of patients with brain metastases. The large number of patients with brain metastases who require care by a neurosurgeon for optimal treatment has significant implications for both the patterns of neurosurgical training and practice in the United States.     

Intracranial metastasis of thymoma: report of three cases

Thymoma with metastasis to the central nervous system is extremely rare. Herein, three rare cases of thymoma with intracranial metastasis are reported. Case 1 (thymoma, B3 in the WHO classification); cranial magnetic resonance imaging (MRI) revealed a mass lesion with a ring enhancement effect in the right temporal lobe. The cystic and hemorrhagic lesion was subtotally removed and radiation therapy of 40 Gy was administered to the tumor cavity containing the remains of the tumor around the ependyma. The patient received combination chemotherapy with carboplatin and gemcitabine hydrochloride, and he was discharged 3 months after the operation. Case 2 [(thymoma, C (thymic carcinoma)]; multiple cerebral metastases of 8 lesions were found and whole brain irradiation of 40 Gy was performed. Three months later, rapid development of 2 metastatic lesions resulted in the patient's death. At autopsy, neoplastic lesions were found in the neck lymph node, right shoulder, chest frame, pleural cavity, diaphragm, lung, periaortic lymph node, liver and pancreas. Case 3 (thymoma, B2); computed tomography (CT) scan and MRI showed a tumorous lesion over the cerebellar hemisphere. At operation, a vascular, elastic-soft and grey tumor was found to originate from the dura mater and had invaded the occipital bone. The tumor had also invaded the arachnoid membrane and sinus wall but the pia mater was free from invasion. Thereafter local irradiation of 40 Gy was performed to the tumor cavity containing the remains of the tumor around the sinus. However local recurrence reoccured 3 years later. After stereotactic irradiation of 40 Gy to the recurrent tumor, the tumor diminished. The patient is wheelchair-bound 3 years and 4 months after the operation. Most cerebral metastases are extremely rare. Outcome remains poor and life expectancy is very short when brain metastasis is present. Treatment for thymoma is multimodal, including surgery, irradiation and chemotherapy.     

Prognosis after initial recurrence of cutaneous melanoma

We reviewed 231 patients who developed recurrent disease 1 to 218 months after surgical therapy for clinical stage I cutaneous melanoma. Metastatic lesions amenable to surgery, including visceral recurrences, were resected. Adjuvant systemic chemotherapy/immunotherapy or regional hyperthermic perfusion was added in patients with unresected disease. Local irradiation was employed for nonresectable brain or other isolated symptomatic metastases. The overall 5-year survival rate after initial recurrence was 36%. In patients with soft tissue or nodal recurrence, the 5-year survival rates were 49% and 38%, respectively; six (11%) of 53 patients whose initial recurrence was in a visceral organ achieved prolonged remission. Primary lesion anatomic site, thickness, pathologic type, and interval from initial therapy to recurrence were unrelated to survival. Significant prognostic factors included the site of initial metastasis, stage of primary disease, and the successful complete eradication of gross disease by surgical excision or intensive chemotherapy.     

Hypofractionated stereotactic radiotherapy using intensity-modulated radiotherapy in patients with one or two brain metastases

PURPOSE: A small fraction of patients with 1-2 brain metastases will not be suitable candidates to either surgical resection or stereotactic radiosurgery (SRS) due to either their location or their size. The objective of this study was to determine the local control, survival, patterns of relapse and the incidence of brain injury following a course of hypofractionated stereotactic radiotherapy while avoiding upfront whole brain radiation therapy (WBRT) in this subgroup of patients. METHODS: A Gill-Thomas removable head frame system was used for immobilization. Brain LAB software with dynamic multileaf collimator hardware was used to design and deliver an intensity-modulated radiation therapy treatment plan. A dose of 600 cGy was prescribed to the 100% isodose line that would encompass the lesion with a 3-mm margin. A total dose of 3,000 cGy was delivered in 5 fractions using 2 fractions per week. The patients were followed with neurological examination and serial MRI images done every 3 months following the procedure. RESULTS: Twenty patients have been treated using this fractionation schedule since April 2004. The 1-year local control at the site of original disease is 70%. The complete response, partial response and stable disease at the last follow-up were 15, 30 and 45%, respectively. Two patients had local recurrence at the site of original disease, while 5 had evidence of leptomeningeal disease. Two additional patients developed new brain metastases, resulting in a 1-year brain relapse-free survival of 36% following this approach. The median overall survival was 8.5 months. Three patients (15%) developed steroid dependency lasting 3 months or longer following the procedure. Four patients (20%) needed WBRT as salvage following this approach. CONCLUSIONS: The preliminary results of hypofractionated SRS are comparable to both surgery and SRS data for solitary brain metastases in terms of local control and overall survival with acceptable morbidity in this cohort of unfavorable patients.