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.     

Prolonged Survival After Extracranial Metastasectomy From Synchronous Resectable Lung Cancer

Background:Combined resection of solitary synchronous brain metastases and non–small-cell lung cancer has been shown to be successful. Thus, we proposed combining the surgery of solitary, extracranial metastases, and resectable lung cancer.Methods:Between March 1987 and December 1994, surgery was performed on nine patients with non–small-cell lung cancer with synchronous, solitary, extracranial, or distant metastasis: adrenal (n = 5), cutaneous (n = 2), axillary lymph node (n = 1) and kidney (n = 1). Criteria for operating on these patients included: primary tumor that was locally resectable in a radical manner, non–small-cell histology, no preoperative evidence of N2 disease, complete resection of histologically proven metastasis, and absence of other metastases found with computed tomography or bone scan.Results:Resection of the primary tumor and solitary metastases was achieved in all patients. Primary tumor was always resected by lobectomy. No mortality or major morbidity was reported. Five-year survival rate was 55.6%. Five patients who had adrenal (n = 3), or skin (n = 1), or axillary (n = 1) metastases, survived more than 5 years. All N2 patients (n = 2) died.Conclusions:The presence of solitary, distant metastasis should not be considered, per se, a factor for denying surgery for locally resectable, non–small-cell lung cancer. Unexpected, prolonged survival was demonstrated in our limited series.     

A case of long-term survival after pulmonary resection for metachronous pulmonary metastasis of basaloid squamous cell carcinoma of the esophagus

INTRODUCTIONBasaloid squamous cell carcinoma of the esophagus (BSCE) is a rare malignancy among esophageal cancers. We reported a case of 63-year-old woman with metachronous pulmonary metastasis of BSCE, successfully treated by metastasectomy of the left lung.PRESENTATION OF CASEBiopsy specimens of upper gastrointestinal fiberscopy led to diagnosis of poorly differentiated squamous cell carcinoma of the esophagus. Computed tomography revealed metastatic lymph nodes surrounding the bilateral recurrent laryngeal nerve and no evidence of metastasis to distant organs. Curative esophagectomy with three-field lymph node dissection was performed through thoracoscopic approach. Pathological examination of the resected specimens led to diagnosis of BSCE with invasion into the submucosal layer of the esophageal wall. Two years later, a solitary oval-shaped pulmonary lesion of approximately 10 mm was detected in the left lung. Wedge resection of the left upper lobe was performed via thoracoscopic approach. The postoperative course was uneventful. Histologically, the pulmonary lesion was diagnosed as metastatic BSCE. Follow-up indicated no recurrence 9 years after the initial surgery.DISCUSSIONSurgical intervention was acceptable on this case of solitary pulmonary metastasis. However, data are lacking about the efficacy of pulmonary resection for metachronous pulmonary metastasis of BSCE because the postoperative outcome is usually poor. The efficacy of surgical intervention for metastatic lesions of BSCE is debatable and requires further examination.CONCLUSIONAlthough the usefulness of surgical intervention for metastatic lesions from BSCE is controversial, the patients with metachronous solitary metastasis to the lung and without extrapulmonary metastasis would be good candidate for pulmonary resection.     

Resection of brain metastases from non-small-cell lung carcinoma. Results of therapy. Memorial Sloan-Kettering Cancer Center Thoracic Surgical Staff.

The treatment of patients with a solitary brain metastasis has been evolving, with most centers recommending resection in patients with good performance status. To evaluate the results of resection of brain metastases from non-small-cell lung cancer, we reviewed our 16-year experience with 185 consecutive patients undergoing resection of brain metastases from 1974 to 1989, inclusive. There were 89 men and 96 women; ages ranged from 34 to 75 years (median 54). Sixty-five (35%) had synchronous and 120 (65%) metachronous brain metastases. Discounting the brain metastasis, 68 patients (37%) had stage I, 13 (7%) stage II, 62 (33%) stage IIIA, 30 (16%) stage IIIB, and 12 (6%) stage IV carcinoma. There was no significant difference in age, locoregional stage (TN), or histologic features in patients with synchronous versus metachronous lesions. The overall survival rates (n = 185) were as follows: 1 year, 55%; 2 years, 27%; 3 years, 18%; 5 years, 13%; and 10 years, 7% (median 14 months). There was no significant difference in survival between patients with synchronous and metachronous lesions. To evaluate the impact of locoregional stage and treatment of the primary site, we analyzed only those patients with synchronous brain metastases. Multivariate analysis demonstrated that locoregional stage had no significant effect on survival (p = 0.97), but complete resection of the primary disease significantly prolonged survival (p = 0.002). Therefore complete resection, and not stage, of the locoregional primary lesion is the primary determinant of survival in patients undergoing resection of brain metastases from non-small-cell lung cancer.     

Surgeon's role in the management of solitary renal cell carcinoma metastases occurring subsequent to initial curative nephrectomy: An institutional review

Background: Solitary metastases from a primary renal cell carcinoma (RCC) occur in <10% of patients with metastatic RCC. To date, the benefit of surgically resecting such apparently solitary lesions has not been well documented. Materials and Methods: Forty-one patients (25 men, 16 women) with metastatic renal cell carcinoma treated by surgical excision of solitary metastases (1970–1990) were retrospectively reviewed. They comprised 9% of patients with metastatic hypernephroma seen during this period. All patients had undergone previous curative nephrectomy with a median disease-free interval of 27 months. Patients with skeletal, spinal cord, and lymph node metastases were excluded. Results: Mevtastases were intrathoracic (n=20), intracranial (n=7), and intraabdominal or in the extrapleural chest wall soft tissue (n=10). Three patients had metastases to the thyroid gland and one had a solitary metastasis to an index finger. Median follow-up was 3.2 years. Complete resection was possible in 36 patients (88%) with a single lesion excised in 23 of these 36 patients (64%). There was no operative mortality. Predicted survival from the date of complete resection of metastases was 77%, 59%, and 31% at 1, 3, and 5 years, respectively, with a median survival of 3.4 years. One patient is alive without evidence of recurrent tumor 93 months from the first of 12 complete surgical resections. Varying adjuvant therapy was used in 50% of the patients. An increased histological tumor grade of the metastatic lesion relative to the original RCC was the only significant prognostic indicator identified. Disease-free interval and number of resected lesions were not significantly associated with patient survival. Conclusion: A small fraction of renal cell carcinoma patients are candidates for potentially curative surgical resection of solitary metastatic lesions. Excision of such lesions may contribute to prolonged survival in selected instances. The results of this study were presented at the 46th Annual Cancer Symposium of The Society of Surgical Oncology, Los Angeles, California, March 18–21, 1993.     

Solitary colon metastasis from renal cell carcinoma nine years after nephrectomy: A case report

IntroductionRenal cell carcinoma (RCC) is the most common renal malignancy in adults. Metastatic disease is relatively common at presentation and frequently involves the lung, bone, brain, liver and adrenal glands. After curative resection, there is a 30–40% risk of recurrence, and a 10% risk of developing metastatic disease after 5 years. The gastrointestinal tract, particularly the colon, represents a very uncommon site of late metastatic disease.Presentation of CaseWe present a case of a 67 year-old-male who underwent a left radical nephrectomy for RCC 9 years before presenting with a metastatic large bowel obstruction. He was later found to have a near-completely obstructing mass in the rectosigmoid colon and underwent a sigmoidectomy with anterior resection of the upper rectum. Histopathology confirmed metastatic RCC confined to the colonic wall with negative microscopic margins.DiscussionThe tendency of RCC to metastasize to unusual sites such as the pancreas or thyroid gland has been widely reported. However, cases of colon metastasis from RCC are extremely rare. Despite the absence of randomized prospective data, widespread consensus supports the surgical treatment of solitary and oligometastatic disease in light of the poor patient outcomes in non-surgically treated disease (Milovic et al., 2013) [3]. Multiple groups have reported favorable outcomes for surgically resected solitary metastatic disease with long disease-free intervals and good performance status.ConclusionThe colon is a potential, though uncommon, site for solitary metastasis from RCC. The clinical presentation is frequently several years after initial curative resection. Oncologic resection with negative margins may result in long-term survival in patients with isolated metastatic disease.     

Long-Term Survival Achieved by Repeated Resections of Metachronous Pulmonary and Adrenal Metastases of α-Fetoprotein-Producing Gastric Cancer: Report of a Case

We report a case of long-term survival achieved by repeated resections of metastases from -fetoprotein (AFP)-producing gastric cancer. A 59-year-old man initially underwent total gastrectomy with lymph node dissection and resection of the spleen and left adrenal gland, for an advanced AFP-producing gastric cancer. A solitary pulmonary metastasis was resected 2 years later, and then a right adrenal gland metastasis, an inferior vena cava thrombus, and another pulmonary metastasis were resected 6 months, 1 year, and 8 months after each other, respectively. Thus, the patient has survived for 7 years and no further evidence of disease was found at his last follow-up examination. To the best of our knowledge, this is the first case of AFP-producing gastric cancer resulting in metachronous solitary pulmonary and adrenal gland metastases, but not liver metastasis. We report this case to show that for selected cases, surgical resection of these metastases is feasible and may extend survival.     

Impact of surgical resection on survival in patients with metastatic soft tissue sarcoma and comparison between synchronous and metachronous metastases

BackgroundThe role of local surgery in patients with metastatic soft tissue sarcoma (STS) remains unknown. The study aims to assess the clinical outcomes and impact of surgical resection on survival in patients with metastatic STS and elucidate the survival differences between synchronous and metachronous metastatic groups.MethodsAmong the 272 patients with STS treated between 2000 and 2018, 84 with synchronous or metachronous metastasis were included. Associations between overall survival and primary tumor resection and metastasectomy were assessed using multivariate Cox regression analyses to adjust for baseline differences between surgically and non-surgically treated patients. Propensity score matching was applied to compare synchronous and metachronous metastasis.ResultsAmong the 84 patients included, 69 (82%) and 41 (49%) underwent primary tumor resection and metastasectomy, respectively. The 2- and 5-year overall survivals of all patients after first detection of metastasis were 51.1% and 24.4%, respectively. Multivariate analysis showed that size <8 cm, grade <3, and number of metastases <4 were associated with longer overall survival. After adjusting for baseline demographic and tumor characteristics, primary tumor resection and metastasectomy still had favorable effects on survival. Tumor subtypes, grade, and number of metastases differed significantly between synchronous and metachronous groups. However, after adjusting for these valuables, both groups exhibited comparable survival.ConclusionsApproximately one fourth of the patients with metastatic STS survived for >5 years. Our results showed that surgical resection of primary tumors or metastatic lesions had favorable impact on survival even after adjusting for patient backgrounds, with comparable survival observed between those with synchronous and metachronous metastases.     

肺癌脑转移同期手术切除：（附7例报告）

７例肺癌脑转移病人同期做肺叶切除（其中有１例单纯探查）和颅内转移瘤摘除术。其中３例存活１２￣２４个月，１例至今已存活２．５年。说明有脑转移的晚期肺癌行联合病灶切除可明显延长生存期，文中对病例选择和手术方法进行了讨论。     

Video-assisted thoracoscopic wedge resection of solitary pulmonary metastasis from hepatocellular carcinoma

We report a metastatic pulmonary tumor resected by video-assisted thoracoscopic surgery. A 63-year-old female was found to have four nodules of hepatocellular carcinoma (HCC) in January 1991; after non-surgical treatment, the tumors had become necrotic. In June 1992, a new HCC nodule was found. After infusion chemotherapy, it became necrotic. In September 1993, a solitary lung tumor, 2.4 cm in diameter, appeared at the periphery of the right lung. Because the tumor was considered to be a metastatic HCC rather than a primary lung cancer, it was removed by thoracoscopic wedge resection. Although whether metastasectomy contributes to prolongation of survival is still controversial, thoracoscopic pulmonary resection may be indicated for solitary peripheral metastasis, if the primary HCC is well controlled by multidisciplinary treatment.     

Pancreatic resection for renal cell carcinoma metastasis: An exceptionally rare coexistence

IntroductionPancreatic metastases are uncommon and only found in a minority of patients with widespread metastatic disease at autopsy. The most common primary cancer site resulting in pancreatic metastases is the kidney, followed by colorectal cancer, melanoma, breast cancer, lung carcinoma and sarcoma.Presentation of caseHerein, we report a 63-year-old male patient who presented −3.5 years after radical nephrectomy performed for renal cell carcinoma (RCC)-with a well-defined lobular, round mass at the body of the pancreas demonstrated by abdominal Magnetic Resonance Imaging (MRI). The patient underwent distal pancreatectomy combined with splenectomy and cholecystectomy. Histopathological examination revealed clusters of epithelial clear cells, immunohistochemically positive for RCC marker, and negative for CD10 and CA19-9. A final diagnosis of clear RCC metastasizing to pancreas was obtained in view of the past history of RCC, microscopy and the immunoprofile. This was the second metachronous disease recurrence after a previous metastatic involvement of the liver, developed 19 months from the initial diagnosis. The patient has remained well at a 6 month follow up post-resection.DiscussionSolitary pancreatic metastases may be misdiagnosed as primary pancreatic cancer. However, imaging including computed tomography (CT) and MRI, may discriminate between them. Surgical procedures could differentiate solitary metastasis from neuroendocrine neoplasms. The optimal resection strategy involves adequate resection margins and maximal tissue preservation of the pancreas.ConclusionRecently, an increasing number of surgical resections have been performed in selected patients with limited metastatic disease to the pancreas. In addition, a rigid follow-up scheme, including endoscopic ultrasound (EUS) and CT is essential give patients a chance for a prolonged life.     

Resection of brain metastases from sarcoma

Background: Brain metastases from sarcoma are rare, and data concerning the treatment and results of therapy are sparse. Methods: We retrospectively reviewed 25 patients with brain metastases from sarcoma of skeletal or soft-tissue origin, surgically treated in a single institution during 20 years. Results: In 18 patients the brain lesion was located supratentorially, and in 7 patients infratentorially. Median age at brain metastasis diagnosis was 25 years. Median time from primary diagnosis to diagnosis of brain metastasis was 26.7 months. Lung metastases were present in 19 patients and in 8 patients they were synchronous with the brain lesion. Pulmonary metastases were resected in 12 patients (48% of total, and 63% of those with pulmonary lesions). The overall median survival from diagnosis of the primary sarcoma was 38 months and from craniotomy was 7 months. The presence or absence of lung lesions did not alter the median survival as calculated from diagnosis of brain metastasis. Overall percent survival was 40% at 1 year and 16% at 2 years. Conclusions: Because brain metastases from sarcoma are refractory to alternative treatment, surgical excision is indicated when feasible. Brain metastases from sarcoma are uncommon, usually occurring with or after lung metastasis. Long-term survival is possible in some patients.Results of this study were presented at the 47th Annual Cancer Symposium of the Society of Surgical Oncology, Houston, Texas, March 17–20, 1994.     

Long-term survival after surgical resection of metachronous inguinal lymph node and contralateral lung metastases from lung cancer; report of a case

The majority of patients with metastatic diseases are not indicated for radical surgery because of another metastatic lesions. We herein describe a case of long-term survival after surgical resections of metachronous inguinal lymph nodal and contralateral pulmonary metastases from lung cancer. In August 1999, a 71-year-old man presented with hemosputa. Chest computed tomography (CT) showed a tumor of the right lung. In January 2000, the right upper lobectomy was performed, and thereafter the lesion was diagnosed as a large cell carcinoma. Two months later, a groin tumor was detected, diagnosed as a metastatic lesion with aspiration cytology, and resected. In October 2001, a newly developing lung tumor in the left upper lobe was detected by routine chest CT. In December 2001, a partial resection of the left upper lobe was performed, and the tumor was diagnosed as a large cell carcinoma. The patient is alive without recurrence for 5 years.     

Long-term survival after surgical resection of liver metastasis from lung cancer

Lung cancer metastasis to the liver indicates a poor prognosis, and the majority of patients with metastatic disease to the liver are not indicated for surgery because of the number or distribution of metastases or the presence of extrahepatic disease. We herein describe a case of long-term survival after a surgical resection of liver metastases from lung cancer. Six months after surgery for Stage IB primary lung adenocarcinoma, a 71-year-old male was found to have a metastatic tumor in his liver. A hepatic resection for the metastatic tumor and another small metastatic foci found intraoperatively was carried out, and the tumors were pathologically diagnosed as liver metastases from lung cancer. The patient is presently alive and well without recurrence, as of 5 years and 2 months after the liver resection. This is the first report of the successful surgical treatment of liver metastasis from lung cancer.     

Calcified metastatic brain tumor--two case reports

A 29-year-old man and a 46-year-old woman presented with calcified brain metastasis from pulmonary adenocarcinoma. Both patients had a relatively benign clinical course and prolonged survival after total removal of the tumors. The male patient was still alive 2 years 3 months after surgical resection of the metastatic and primary tumors. The female patient had had brain metastasis 8 years after surgical resection of lung cancer, and survived for 3 years 3 months after removal of the brain metastasis. The MIB-1 indexes of the two cases were relatively low compared with other cases of brain metastases. Calcification and low MIB-1 index may indicate longer survival in patients with metastatic tumors if the primary tumor is controlled.     

Surgical treatment for brain metastases: prognostic factors and survival in 177 patients

Brain metastases are an increasingly frequent complication of cancer. Advances in diagnosis and treatment have led to wider indications for surgery. We present a single-institution series of 177 patients and discuss our results with regard to the literature. Special focus is on patients with advanced age, multiple brain metastases, extracranial metastases, and brain metastasis recurrence. All patients underwent craniotomy for the resection of solid tumor brain metastases between 1994 and 2001 in our department. Perioperative morbidity and mortality as well as survival were evaluated. The median patient age was 59 years (range 32–86 years). In 177 patients, 348 brain metastases were detected, of which 68.0% were supratentorial and 32.0% were infratentorial. According to univariate analysis, the following parameters were significantly associated with prolonged patient survival: (1) age <70 years, (2) one to three intracranial metastases, (3) favorable postoperative performance, (4) resection of all intracranial lesions, and (5) recraniotomy for brain metastasis recurrence. In contrast, the presence of extracranial metastases, metachronous diagnosis, and solitary brain metastases had no influence on survival. As expected, younger age and limited number of brain metastases (up to three) are favorable prognostic factors. Remarkably, the presence of extracranial metastases had no influence on patient survival.     

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)诊断及治疗情况。(2)随访及生存情况。(3)预后影响因素分析。采用门诊和电话方式进行随访,了解病人术后生存情况,随访时间截至2018年12月。正态分布的计量资料以x±s表示,偏态分布的计量资料以M(范围)表示。计数资料以绝对数或百分比表示。采用Kaplan-Meier法计算生存率并绘制生存曲线,单因素分析采用Log-rank检验,多因素分析采用COX比例风险模型。结果(1)诊断及治疗情况:63例结直肠癌肺转移病人中,同时性肺转移6例,异时性肺转移57例。18例病人胸部X线片检查初始发现肺部可疑转移灶,经X线计算机体层摄影术(CT)检查进一步证实为肺转移灶,45例病人胸部CT检查初始发现肺转移灶。63例病人均行原发灶和肺转移灶根治性R 0切除术。22例病人行纵隔淋巴结清扫,其中2例各有1枚纵隔淋巴结转移。所有病人术后恢复良好,未出现严重并发症。63例病人中,57例接受>6个月以氟尿嘧啶类药物为主的术后辅助化疗及靶向治疗。(2)随访及生存情况:63例病人均获得术后随访,随访时间为8~143个月,中位随访时间为58个月。63例病人中,19例死亡,24例出现二次复发,5年复发率为38.1%(24/63),复发时间为18个月(3~58个月)。24例二次复发病人中,19例发生肺转移,3例发生脑转移,2例发生骨转移,2例发生肝转移。同1例病人可同时发生多处转移。24例二次复发病人中,5例行再次手术治疗,19例行化疗和放化疗。63例病人5年总体生存率为62.7%。(3)预后影响因素分析:单因素分析结果为原发灶部位、肺转移灶数目和肺转移灶切除术前癌胚抗原水平是影响结直肠癌肺转移病人预后的相关因素(χ²=4.162、7.175、6.725,P<0.05)。多因素分析结果显示:肺转移灶数目和肺转移灶切除术前癌胚抗原水平是结直肠癌肺转移病人预后的独立影响因素(风险比=2.725,2.778,95%可信区间为1.051~7.064、1.072~7.021,P<0.05)。结论根治性手术切除结直肠癌肺转移灶安全、可行。肺转移灶数目和肺转移灶切除术前癌胚抗原水平是结直肠癌肺转移病人预后的独立影响因素。     

Curatively resected isolated inguinal lymph node metastasis from cecum cancer: report of a case

We herein report the case of a curatively resected solitary inguinal lymph node metastasis from cecum cancer. Our patient was a 67-year-old male with cecum cancer with abdominal wall invasion. Three years after surgery, inguinal lymph node swelling was detected by a computed tomography examination. Further examination revealed no other metastases. Surgical resection was performed to remove the lesion, and microscopic examination revealed that cancer cells had metastasized. No recurrence was detected 3 years after the salvage surgery. Inguinal lymph node metastasis of cecum cancer has not been reported in the literature, but in our case salvage surgery resulted in a good outcome.     

Colorectal lung metastases: results of surgical excision.

Between 1960 and 1988, 139 consecutive patients underwent pulmonary resection for metastatic colorectal carcinoma. Median interval between colon resection and lung resection was 34 months. Ninety-eight patients (70.5%) had a solitary metastasis. Wedge excision was performed in 68 patients, lobectomy in 53, lobectomy plus wedge excision in 9, bilobectomy in 4, and pneumonectomy in 5. Operative mortality was 1.4%. Localized extrapulmonary colorectal cancer was also resected in 20 patients. Median follow-up was 7 years (range 1 to 20.4 years). Overall 5- and 20-year survival was 30.5% and 16.2%, respectively. Five-year survival for patients with solitary metastasis was 36.9%, as compared with 19.3% for those with two metastases (p less than 0.05) and 7.7% for those with more than two (p less than 0.01). Patients with normal carcino-embryonic antigen had a 5-year survival of 46.8% versus 16.0% for patients with increased levels (p less than 0.01). Five-year survival for patients with resected extrapulmonary disease was 30.0% versus 30.7% for those without extrapulmonary cancer (p = not significant). Repeat thoracotomy for recurrent metastases was done in 19 patients. Five-year survival after the second lung resection was 30.2%. We conclude that resection of colorectal lung metastases is safe and effective, that resectable extrapulmonary disease does not necessarily contraindicate pulmonary resection, and that repeat thoracotomy is warranted in selected patients with recurrent colorectal lung metastases.