A 65-year-old man is brought to the emergency department after having a seizure. Past 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 cm x 3.5 cm) in the right hemisphere at the grey-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 and started on phenytoin. Which of the following is the most appropriate next step in the management of this patient?

Question

A 65-year-old man is brought to the emergency department after having a seizure.  Past 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 cm x 3.5 cm) in the right hemisphere at the grey-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 and started on phenytoin.  Which of the following is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

Metastatic brain tumors are the most common type of intracranial brain tumors. They may be solitary or multiple and are usually seen at the grey-white matter junction. Brain metastasis is frequently seen in patients with non-small cell lung carcinoma (NSCLC). Favorable survival outcomes after diagnosis of brain metastases include age <65 years, good functional performance status, and stable extracranial disease. Aggressive treatment is typically indicated in such patients to improve survival and control central nervous system disease. For patients with a single brain metastasis in a surgically accessible location and good performance status, surgical resection offers the best therapeutic option. This is typically followed by stereotactic radiosurgery (SRS) or whole brain radiation therapy (WBRT) to the tumor bed. SRS may be used as an alternate therapeutic option for patients who are not candidates for surgery, have a surgically inaccessible lesion, or smaller metastasis (<3 cm). For patients with multiple brain metastases or poor performance status, WBRT or supportive care is typically recommended (Choice E). (Choice A) Brachytherapy involves implantation of a radioactive source directly into an intracerebral mass or surgical cavity, allowing higher radiation doses to be delivered directly into the brain without affecting other organs. It is typically used in conjunction with surgery, or after recurrence following WBRT or surgery. (Choice B) Chemotherapy might be used in case of brain metastasis from chemosensitive tumors (eg, small cell lung cancer, lymphoma, choriocarcinoma). However, it has not shown to be beneficial in the management of brain metastasis from NSCLC. (Choice C) This patient has good performance status and no evidence of extracranial metastases. He should be treated aggressively to improve survival. The median survival time for patients who receive supportive care and are treated only with corticosteroids is approximately 1-2 months. Educational objective: Surgical resection is recommended for solitary brain metastasis in patients with good performance status and stable extracranial disease. In patients with multiple brain metastases, whole brain radiation therapy is typically used. References: The role of whole brain radiation therapy in the management of newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline (http://www.ncbi.nlm.nih.gov/pubmed/19960231) Diagnosis-specific prognostic factors, indexes, and treatment outcomes for patients with newly diagnosed brain metastases: a multi-institutional analysis of 4,259 patients (http://www.ncbi.nlm.nih.gov/pubmed/19942357) A randomized trial of surgery in the treatment of single metastases to the brain (http://www.ncbi.nlm.nih.gov/pubmed/2405271)

A 65-Year-Old Man Is Brought to the Emergency Department After