The development of brain metastasis in a patient with non–small-cell lung cancer (NSCLC) is an ominous prognostic sign. About 30% of individuals with NSCLC eventually develop brain metastasis.1 This number increases to about 50% in autopsy series.2 When the metastases are multiple, palliative treatment in the form of radiation therapy is recommended. Solitary brain metastasis, however, can be approached surgically. The proportion of NSCLC patients that develops brain metastasis amounts to approximately 40,000 patients per year. The magnitude of this problem can be appreciated by comparing this number with the incidence of new primary cancers of the pancreas (n = 27,000), stomach (n = 24,000), and esophagus (n = 13,000). The median survival rate of untreated lung cancer with brain metastasis is approximately 1 month. Steroid therapy increases the median survival by 2 months. Whole-brain radiation increases survival by 3 to 6 months.3 Recent reports indicate longer survivals when surgical treatment is combined with whole-brain radiation.4,5 The experience of several large centers that offer a surgical approach to lung cancer with brain metastasis is discussed herein, with an analysis of factors underlying prolonged survival.
In addition, other sites of metastatic disease also commonly present as oligometastases. Patients with lesions to the adrenals, liver, and bone are sometimes amenable to aggressive surgical and multimodality regimens. For the purposes of this chapter, data on brain and adrenal lesions will be presented.
Previous studies have reported 5-year survival rates of 11% to 21% in patients treated with cranial and thoracic resection.5,6 Despite this, many patients are offered palliative treatment only with chemotherapy or radiotherapy after a brain metastasis has been detected. There is controversy regarding the ideal management of thoracic disease in this patient population, and there are few series that incorporate patients treated with craniotomy or stereotactic radiosurgery (SRS).7
Thoracic Resection with Craniotomy or Stereotactic Radiosurgery—Patients and Methods
In our prior series from the University of Maryland, 28 patients with solitary brain metastasis were treated by thoracotomy with resection of lung cancer and craniotomy with excision of brain metastasis or SRS. More recent patients in our series have undergone lung resection and gamma knife stereotactic radiosurgery (GK-SRS). The series consisted of 16 men and 12 women ranging in age from 42 to 70 years, with a mean age of 56.24 years.
The initial presenting symptom was neurologic in 50% of patients. The range of neurologic symptoms included hemiparesis, headaches, monoparesis, ataxia, visual disturbances, seizures, behavioral changes, and mild weakness. In these patients, the onset of the cerebral metastasis was synchronous with the primary in that the pulmonary lesion was identified on the chest x-ray concomitant with the initial presentation of the metastasis. The remainder presented with pulmonary complaints related to their bronchogenic carcinoma, including cough, hoarseness, and chest pain, but later developed symptoms ...