A 60-year-old man is brought to the emergency department after having a seizure. Medical history is significant for non–small cell lung carcinoma diagnosed 2 years ago and treated surgically. He continues to work as a college professor and usually walks 1-2 miles daily. MRI of the brain shows a solitary cortical mass (2 × 3.5 cm) in the right hemisphere at the gray-white matter junction that is most consistent with metastasis. CT scan of the chest and abdomen shows no evidence of recurrent malignancy. The patient is admitted for further management. He would like to treat this recurrence aggressively, if possible. Which of the following is the most appropriate next step in management of this patient?
This patient with a history of non–small cell lung carcinoma has a symptomatic, solitary brain mass consistent with metastasis. There is no evidence of any other metastatic disease. In cases such as this one, surgical resection of the mass usually rapidly improves symptoms (eg, seizures) and increases survival by months to 2 years.
Surgical resection of solitary brain metastases is generally recommended in patients age <65 with good functional performance status and stable (or undetectable) extracranial disease. Targeted radiation therapy (ie, stereotactic radiosurgery) may be used as an alternate therapeutic option (eg, poor surgical candidates, surgically inaccessible lesions, a few/small lesions).
In addition, many targeted therapies may be available based on the molecular pathology of the lesion (eg, immunotherapy). Patients with good functional status are also typically encouraged to enroll in clinical trials for newer therapies.
(Choice A) This patient has good performance status and no evidence of extracranial metastases. Although decision-making should be shared, it is generally recommended to treat solitary brain metastases because doing so can increase survival and improve symptoms.
(Choice B) Brachytherapy involves implantation of a radioactive source (pellet) directly onto the site of cancer, allowing higher radiation doses to be delivered directly into the cancer bed. The pellets are implanted surgically, so they are used in addition to surgical resection rather than as primary treatment. Brachytherapy is commonly used in some cancers (eg, prostate) but is less commonly used to treat brain lesions.
(Choice C) Chemotherapy might be used in case of brain metastasis from chemosensitive tumors (eg, small cell lung cancer, lymphoma, choriocarcinoma); non–small cell lung cancer is not chemosensitive. Compared to surgical resection or targeted radiation, traditional chemotherapy does not seem to be as effective at either reducing symptoms or improving survival in patients with solitary brain metastases.
(Choice E) Whole brain radiation is usually recommended for patients with good performance status who have a high burden of intracranial disease; avoidance of the hippocampus has improved the neurocognitive morbidity of this treatment.
Educational objective:
Surgical resection is recommended for solitary brain metastasis in patients with good performance status and stable extracranial disease.