Pulmonary Cancer with Brain Metastases: Surgical Treatment

B.V. Gaidar, V.E. Parfenov, L.N. Bisenkov, G.E. Trufanov, B.V. Martynov, S.A. Shalaev, V.I. Vasilashko, Yu.M. Baranenko

Kirov Medicomilitary Academy Saint Petersburg, Russia

 

Introduction

The last decades are characterized by publication of both home and foreign reports, describing successful removal of distant solitary metastases after radical resections of malignant tumors with different primary localization [3, 4]. These interventions have been performed on lungs most frequently, as early detection of metastases in them is much easier than in other areas and resection does not entail great technical difficulties. Long-term results demonstrate adequacy of such active surgical tactics. They are quite comparable with five-year survival of patients, who underwent resections for primary pulmonary cancer, and reach 26-36% and more [1].

There is a rather great number of reports, devoted to removal of solitary brain metastases. According to them, such interventions are justified in many cases, as they prolong a patient's life to a consierable extent and improve its quality [2].

Development of surgical tactics in primarily multiple cancer is paid special attention to [1]. It is conditioned by both a greater number of patients with this pathlogy and improvement of modalities, used for diagnosis of malignant tumors with a single-stage or successive origin. Patients with pulmonary cancer and blastomatous changes in the brain present the greatest difficulty from the point of view of surgical tactics. It becomes grounds for giving up surgical treatment. At the same time it is difficult to exclude probability of primarily multiple cancer in such cases. It should be noted, that the rate of primary cerebral tumors is smaller than the rate of cancer metastases. However, they are not an absolte rarity and are diagnosed in 4-5 people per 100 000 men annually. Surgical treatment, including lung resection and removal of brain tumor, seems to be justified, though it demands a differentiated approach in each specific situation. Besides, this approach is considered to be adequate in those cases, when development of malignant pulmonary tumor is accompanied by appearance of its solitary metastasis in the brain.

Complexity of rendering expert care to such patients is conditioned not only by peculiarities and interaction of arising pathologic disorders with structural and functional origin, but also by necessity of coordinated activity of surgeons and neurosurgeons.

Material and Methods

There were 16 patients with pulmonary cancer and brain metastases, treated in clinics of the Medicomilitary Academy in 1999-2004. Being devoted adherents of one-stage simultaneous interventions in primarily multiple cancer of the lung and other organs, we tried to base treatment just on this principle.

There were 14 males and 2 females, aged 44-65. Complaints, which made them search for medical care, were rather peculiar. Different manifestations of brain lesion were watched in 12 patients. Due to this fact, the majority of them were admitted to the Clinic of Neurosurgery.

Special diagnostic examinations were aimed at revealing localization, histological structure and a stage of development of primary pulmonary tumor (Fig.1), (Fig.2), as well as spread and a character of blastomatous changes in the brain (Fig.3), (Fig.4), (Fig.5). Other possible metastases beyond limits of the lung and brain were searched for (Fig.6). PET, MRI, CT, ultrasonic and endoscopic methods were the most informative modalities, used with this purpose.

As we thought of possible intervention, functional and reserve potentialities of vital systems of the body were estimated in detail and drug correction of diagnosed accompanying disorders was carried out.

Obtained results showed, that surgical treatment was inexpedient in 7 out of 16 cases. This decision was founded on extensive spread of pulmonary cancer in 6 patients (multiple metastases beyond the limits of the lung and brain or within the limits of the brain). It was caused by marked reduction of functional and reserve potentialities of respiration and circulation in 1 case.

One-stage interventions were performed in 9 patients with pulmonary cancer and solitary brain metastases. The main information on these cases with taking into account data of morphologic examination of surgical specimens is presented in Table 1.

Table 1

Localization and Histologic Structure of Tumors

Localization of Tumor in the Lung

A Histologic Structure of Tumor

Intrathoracic Development of Tumor
(stages, and N criteria)

Localization of Solitary Metastasis of the Cancer

The right lung:

 

 

 

Upper lobe

Nonkeratinising squamous cell carcinoma

Stage III, T2 N2

Right hemisphere

Primary bronchus

Nonkeratinising squamous cell carcinoma

Stage III, T3 N2

Left hemisphere

Lower lobe

Squamous cell moderately- differentiated cancer

Stage III, T2 N2

Left hemisphere

Upper lobe *

Nonkeratinising squamous cell carcinoma

Stage III, T2 N2

Right hemisphere

The left lung:

 

 

 

Upper lobe

Nonkeratinising squamous cell carcinoma

Stage III, 2 N2

Right hemisphere

Lower lobe

Small cell cancer

Stage III, N2

Right hemisphere

Upper lobe

Small cell cancer

Stage II, T2 N1

Cerebellum right hemisphere

Lower lobe

Adenocarcinoma

Stage III, N1

Left hemisphere

Upper lobe

Adenocarcinoma

Stage II, T1 N1

Left hemisphere

* - the second endependent tumor (hypernephroma of the right kidney) was diagnosed and removed during simultaneous intervention (T2 N0 M0).

It can be seen, that a histological structure of cancer in the majority of patients belonged to a category of low-grade forms. At the same time signs, characterizing intrapulmonary and intrathoracic development of a tumor, were indicative of its grave stage on admission and presence of metastases in mediastinal groups of regional lymphatic nodes. It correlates with existing conceptions of a higher risk of distant hematogenic metastases, which appear in internal organs, including the brain, by this time. These metastases are the most frequent cause of death during a short period of time (up to a year); it also concerns patients, who underwent "radical" resection of the lungs. That is why, purposeful examination of each patient with pulmonary cancer of the III stage allows to determine extensiveness of blastomatous changes beyond the limits of a thoracic cavity more precisely and to make attempts, aimed at removal of solitary metastasis of brain tumor in some cases.

Results

Extended pneumoectomy and lobectomy were made in 4 and 5 cases respectively (Fig.7). When a thoracic stage of simultaneous interventon was completed, a patient was placed in a position, which was convenient for performing the second stage, i.e. removal of solitary metastasis from the brain (Fig.8), (Fig.9). It was done by a team of neurosurgeons.

We managed to reduce total duration of simultaneous operations for pulmonary cancer with brain metastases from 5 to 4 hours. It was achieved due to better coordination of activity of all the participants.

Management in a postoperative perod was carried out with participation of resuscitators of the Clinics of Neurosurgery and Thoracic Surgery. It should be mentioned, that treatment in a specialized medical establishment does not differ from conventional therapy of patients, operated on the brain or lungs. The majority of treatment programs, used after one-stage simultaneous and traditional operations, coincided or supplemented each other. Some peculiarity in treatment of patients, subject to lung resection and removal of solitary brain metastasis, lay in monitoring and regular drainage of the tracheobronchial tree in the nearest postoperative period. It was conditioned by natural reduction of motor-evacuating ability of the airway, caused by operation trauma at a thoracic stage of intervention and by impaired central regulation, resulting from removal of solitary brain metastasis. The most effective method was evacuation of pathologic contents from a lumen of the tracheobronchial tree with the help of a fiberoptic bronchoscope; it was done during the first 2-3 days after simultaneous intervention up to the moment of restoration of independent and full-value sputum discharge.

There were no complications in a postoperative period and all the patients were discharged from the Clinic.

All the cases, who had not been operated on, died during a year. A direct cause of their deaths was progressive dislocation syndrome, being the result of brain metastases of pulmonary cancer.

As for 9 operated cases, 6 and 1 of them remained alive during 1.5-2 and 4 years respectively; 2 patients, operated on in June of 2003 and March of 2004, were discharged with evident improvement of their state.

Causes of death in a group of operated patients were confirmed by the results of postmortem examination in 4 cases. One patient died of cerebral disorders, which developed due to impaired blood circulation; there were no signs of a tumor recurrence. A relapse in the area of removal of solitary brain metastasis was watched in 2 cases; 1 patient died of multple metastasizing of small cell cancer into a contralateral lung; there were no local relapses both in the brain and operated lung.

Thus, though simultaneous interventions in pulmonary cancer with solitary brain metastasis are a rather complicated task, they allow not only to obtain a stable palliative effect and to eliminate the most distressing and poignant manifestations of the disease, but also to prolong life of some patients.

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