treat solitary lung brain mets with surgical resection

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.