A 58-year-old woman comes to the emergency department with 5 days of progressive headaches and dizziness. She is a business executive who is very active in her spare time. She takes no medications.
Her vital signs are within normal limits. Examination shows bilateral normal reflexes and sensation and no neck stiffness. Pupils are equal and reactive to light. Gag reflex is intact. There is no peripheral lymphadenopathy.
Laboratory results are as follows:

CT scan of the head with contrast shows a solitary frontal 2x3 cm lesion at the gray-white matter junction with vasogenic edema confirmed on magnetic resonance imaging. CT scan of the chest, abdomen, and pelvis reveals a spiculated 2.5 cm right upper-lung mass with ipsilateral bronchial lymphadenopathy but no other evidence of metastatic disease.
Which of the following is the most appropriate next step in management of this patient's brain lesion?

Question

A 58-year-old woman comes to the emergency department with 5 days of progressive headaches and dizziness.  She is a business executive who is very active in her spare time.  She takes no medications.
Her vital signs are within normal limits.  Examination shows bilateral normal reflexes and sensation and no neck stiffness.  Pupils are equal and reactive to light.  Gag reflex is intact.  There is no peripheral lymphadenopathy.
Laboratory results are as follows:

CT scan of the head with contrast shows a solitary frontal 2x3 cm lesion at the gray-white matter junction with vasogenic edema confirmed on magnetic resonance imaging.  CT scan of the chest, abdomen, and pelvis reveals a spiculated 2.5 cm right upper-lung mass with ipsilateral bronchial lymphadenopathy but no other evidence of metastatic disease.
Which of the following is the most appropriate next step in management of this patient's brain lesion?

Quizplus · Accepted Answer

11ec193a_9618_86a5_853d_d122bc412a27_MD0002_00 Nearly 40% of patients with systemic cancer develop brain metastases, usually through hematogenous spread. Imaging features suggesting metastatic disease include circumscribed margins, location at the gray-white matter junction, patterns of vasogenic edema, and multiple lesions. The most common underlying primary tumors are lung, renal cell, breast, colorectal, and melanoma. This patient likely has primary lung cancer, which may be small cell (SCLC) or non-small cell (NSCLC). Brain metastases from SCLC appear to respond initially to chemotherapy, but studies have shown variable overall response rates without significant survival benefit. Adding whole-brain radiation (WBRT) improves the response rate to chemotherapy but without significant survival benefit. NSCLC is not as chemosensitive as SCLC, and brain metastases respond better to WBRT and/or surgical resection. As a result, surgical resection is usually considered for brain metastases due to SCLC or NSCLC. Options for treating solitary lung-brain metastases include surgical resection followed by WBRT or stereotactic radiosurgery with or without WBRT. Surgery or stereotactic radiosurgery followed by WBRT reduces the risk of tumor recurrence and the likelihood of neurologic death (Choice E). Surgical success depends on resectability, feasibility of decreasing mass effect, proximity to vital areas, age, and performance status. Patients with a resected solitary lung-brain metastasis have a median survival of 40 weeks. This patient with likely primary lung cancer should undergo resection without the need for brain biopsy. (Choice B) Systemic chemotherapy has poor penetration of the blood-brain barrier and is not very effective for brain metastasis. Systemic chemotherapy should be started after treatment of brain metastasis. (Choice C) This patient has good performance status, meets the criteria for resection, and is interested in treatment. Hospice care is not indicated at this time. Palliative care services can be added to assist in overall management of this patient once the brain metastasis is addressed. (Choice D) Sunitinib is a multi-targeted receptor tyrosine kinase inhibitor that is indicated for treating renal cell carcinoma, gastrointestinal stromal tumors, and advanced pancreatic neuroendocrine tumors, not for metastatic lung cancer to the brain. Educational objective: Patients with solitary brain metastasis benefit from surgery or stereotactic radiation followed by whole-brain radiation. __________ References: Nonsmall cell lung cancer presenting with synchronous solitary brain metastasis. (http://www.ncbi.nlm.nih.gov/pubmed/16572401)

A 58-Year-Old Woman Comes to the Emergency Department with 5