Solitary Brain Lesion Research Articles

Solitary Brain Lesions Enhancing at MR Imaging: Evaluation with Fluorine 18–Fluorocholine PET

To prospectively determine whether differences between benign and malignant brain lesions can be depicted with fluorine 18 ((18)F) fluorocholine positron emission tomography (PET). Thirty consecutive patients (14 women, 16 men; age range, 26-79 years) with solitary brain lesions that were enhanced at magnetic resonance (MR) imaging underwent whole-brain (18)F-fluorocholine PET after giving informed consent in this institutional review board-approved, HIPAA-compliant study. Histopathologic diagnoses were made in 24 cases (13 high-grade gliomas, eight metastases to the brain, and three benign lesions). In six cases, benign lesions were diagnosed on the basis of longitudinal follow-up MR findings. The maximum standardized uptake value (SUV(max)) for lesion and peritumoral regions was measured on PET images, and a lesion-to-normal tissue uptake ratio (LNR) was calculated. Differences were assessed with one-way analysis of variance, Fisher exact, and Student t tests. Differences in SUV(max) between high-grade gliomas (1.89 +/- 0.78 [mean +/- standard deviation]), metastases (4.11 +/- 1.68), and benign lesions (0.59 +/- 0.31) were significant (P < .0001). LNRs also differed significantly (5.15 +/- 2.51, 10.91 +/- 2.14, and 1.28 +/- 0.32, respectively; P < .0001). These differences were also significant at pairwise analysis. The peritumoral LNR exceeded 2.0 in seven high-grade gliomas and no metastases (P = .02). In 14 radiation-treated patients, the lesions classified as benign demonstrated significantly less uptake compared with the recurrent tumors (SUV(max): 0.72 +/- 0.38 vs 2.27 +/- 1.24, P < .01; LNR: 1.36 +/- 0.43 vs 5.88 +/- 3.66, P < .01). High-grade gliomas, metastases, and benign lesions can be distinguished on the basis of measured fluorocholine uptake. Increased peritumoral fluorocholine uptake is a distinguishing characteristic of high-grade gliomas.

Prognostic factors associated with brain metastases from epithelial ovarian carcinoma

Brain metastasis from epithelial ovarian carcinoma (EOC) is managed by a multimodal treatment approach. Thus, to determine the prognostic factors associated with this situation is important for management decisions regarding the type of treatment and aggressiveness of treatment. From 1995 to 2005, 13 patients with brain metastases resulting from EOC underwent treatment at Samsung Medical Center. We retrospectively reviewed the medical records to determine prognostic factors and to evaluate treatment outcome. The median age at diagnosis for primary ovarian carcinoma and brain metastasis was 52 and 55 years, respectively. Median interval to brain metastases was 28 months after the diagnosis of EOC. At the time of analysis, nine patients had died of disease. The median survival from brain relapse was 7 months. A Karnofsky performance status of 70 or higher, primary control, solitary brain lesions, recursive partitioning analysis (RPA) class, and treatment modality including gamma-knife radiosurgery (GKRS) were related to survival on univariate analyses. Multivariate analysis showed that treatment modality including GKRS was a more important prognostic factor than RPA class (P = 0.04). This small series demonstrated that GKRS can be a valuable modality for the management of brain metastasis in patients with EOC. Therefore, a better outcome can be achieved by choosing GKRS in their treatments in selected patients.

Stereotactic radiosurgery for brain metastases: results and prognostic factors.

This study was conducted to determine prognostic factors for tumor response and patient survival after stereotactic radiosurgery (SRS) for brain metastasis. Eighty-four patients with brain metastasis underwent SRS at a single institution. After fixation of the head with a stereotactic frame, computed tomography treatment planning was performed. The metastatic lesion was treated with multiple arcs to a median dose of 19 Gy. Forty-seven patients (56%) had a solitary brain lesion. Fifty-nine patients (70%) had evidence of extracranial disease at the time of SRS. The median survival duration from SRS was 7 months. Sixty-three percent of the patients had an objective radiographic response to SRS, which in turn was associated with superior central nervous system control. Age, collimator size, number of arcs, tumor location, and histology did not influence objective response rates. Patients who had a solitary lesion or who received treatment within 2 weeks after diagnosis were more likely to have an objective response than were those who did not (P < 0.05). Progressive brain disease accounted for 37% of the deaths. Nineteen patients (23%) had an in-field relapse. Four severe complications were attributed to SRS. This study confirms the role of SRS as an acceptable treatment option for patients with solitary or limited brain metastases. Int. J. Cancer (Radiat. Oncol. Invest.) 90, 157-162 (2000).

Hepatoblastoma metastatic to brain: prolonged survival after multiple surgical resections of a solitary brain lesion.

Pulmonary metastases of hepatoblastoma confined to the lung have been cured using therapy that included radical surgical resection. We report the case of a child with a hepatoblastoma metastatic to brain that was successfully treated with multiple surgical resections, irradiation, and chemotherapy. The case demonstrates that such an approach, employing aggressive surgery, can produce durable remission of an extrapulmonary metastasis with hepatoblastoma. A 17-month-old girl presented with a hepatoblastoma that remained unresectable after chemotherapy and irradiation and underwent orthotopic liver transplantation 14 months after diagnosis. After twice undergoing surgical resections of pulmonary metastases 22 and 31 months from diagnosis, 1 month later (32 months from diagnosis), she developed a solitary metastatic right brain lesion that later recurred twice in the same location, 5 and 6 years from initial diagnosis. Each time she underwent surgical resection of the brain lesion and received local irradiation after the first two resections and chemotherapy after the third. At the last surgery, resection was continued until histologically negative tumor margins were obtained. The child is currently without evidence of disease or neurological deficit 10.5 years from initial diagnosis. The durable remission achieved after multiple resections of the recurrent solitary cerebral metastasis in this child demonstrates that an aggressive surgical approach to extrapulmonary metastases in such a setting can contribute to prolonged survival, just as has been shown with isolated metastatic pulmonary disease.

Analysis of prognostic factors for patients with single brain metastasis treated with stereotactic radiosurgery.

To evaluate and define treatment prognostic factors and selection criteria for patients with solitary brain metastasis treated with stereotactic radiosurgery. Between March 1990 and January 1995, 48 patients with solitary brain metastasis were treated with stereotactic radiosurgery at our tertiary care institution. Eleven patients were treated for progression or relapse of intracranial disease after whole-brain external beam radiotherapy or surgical resection. Patients were eligible for radiosurgery if they had a (1) Karnofsky Performance Status (KPS) of at least 70, (2) a solitary, radiographically distinct lesion < 4 cm in diameter, (3) lesion at least 1 cm from the optic chiasm, and (4) a reasonably well-controlled primary tumor. The factors subjected to univariate and multivariate analysis for local control and survival correlations were age, histology, control of systemic disease, surgical debulking, whole-brain irradiation, dose delivered, lesion volume, location (supratentorial vs. infratentorial), and new versus recurrent metastasis. Sex and initial KPS were also analyzed for survival. Local control was achieved in 39 (81%) patients. The only prognostic factor in the univariate analysis that significantly correlated with local control was new versus recurrent lesion (P = .009). Initial KPS of at least 80 and age < 65 years were significant with regard to survival in the univariate and multivariate analyses. Median survival after radiosurgery was 8 months. This study corroborates the usefulness of stereotactic radiosurgery for patients with a small solitary metastatic brain lesion. In our series, as well as in others, several characteristics (young age, optimal KPS, newly diagnosed metastasis, controlled or absent systemic disease) provide clues as to which patients will most benefit. Studies, including randomized trials, are needed to clarify patient and tumour characteristics that predict which patients will benefit from stereotactic radiosurgery.

Radiologic Evaluation in Chest Malignancies: A Review of Imaging Modalities

Radiologic evaluation of the patient with non-small cell lung cancer (NSCLC) includes chest radiographs for detecting nodules, computed tomography (CT) for further characterizing them, CT and magnetic resonance imaging (MRI) to evaluate the mediastinum, and extrathoracic imaging of bones, the adrenal gland, the central nervous system, and liver. The current practice standards for each are reviewed. Asymptomatic solitary pulmonary nodules, which are usually detected on chest radiographs obtained for other indications, inevitably require a precise diagnosis. The radiologic characteristics that differentiate benign from malignant pulmonary lesions are given. Mediastinal CT is the preferred modality for examining the mediastinum in patients with NSCLC. Magnetic resonance imaging is used selectively, eg, in patients with superior sulcus tumors who are candidates for surgery. When evaluation for N2/N3 disease is requested, mediastinoscopy should replace CT using the latter as a "roadmap." The role of extrathoracic imaging in evaluating asymptomatic patients with NSCLC at initial presentation is equivocal. Computed tomographic scanning of the head is reasonable in most patients with lung cancer, given the significant incidence of occult brain metastases in this population and that solitary brain lesions may be resected in some protocol settings. Routine liver and adrenal gland scanning is similarly controversial. Bone scans do not appear to be useful in patients with NSCLC unless they have clinical signs, symptoms, or laboratory findings to indicate possible metastases. Although heavily affected by local practice, radiologic evaluation of the patient with NSCLC should attempt to provide accurate determination of local disease and a search for distant metastases.

Treatment of Brain Metastases from Bladder Cancer

The records of 28 patients with transitional cell cancer who had brain metastases were retrospectively reviewed. Data from 19 patients were considered suitable for analysis and were included in this study. One patient was treated with surgery alone, 10 with radiation alone and 7 with radiation and surgery, while 1 received no treatment. Mean and median survival times, respectively, were 57 and 42 months from the initial diagnosis, and 11 and 4 months from diagnosis of central nervous system metastases. Patients treated with surgery and radiation demonstrated a mean survival time of 19 months compared to 6 months for patients treated with radiation alone (p = 0.03). There were 2 long-term survivors in the combined modality group at 50 and at 12 months. Enthusiasm for combined modality treatment should be tempered by the fact that selection bias favored the combined modality group; 13 patients with single lesions demonstrated a mean survival of 14 months compared to 3 months for 6 patients with multiple lesions (p = 0.009) and only patients with solitary lesions underwent surgical resection. Brain metastases have an ominous prognosis in patients with bladder cancer primaries. Considering the sum of the retrospective and prospective reports, we recommend that patients with solitary brain lesions and good performance status be aggressively managed with surgical resection and postoperative radiation therapy.

Long-term follow-up for brain metastases treated by percutaneous stereotactic single high-dose irradiation

Surgery is considered the treatment of choice for solitary brain lesions, and radiation therapy is indicated for metastases only in vital or sensitive regions that cannot be excised without risk of disabling neurologic defects. In these cases, radiosurgery may be an alternative to conventionally fractionated radiation therapy. At the Heidelberg linear accelerator-based radiosurgery facility, 69 patients were treated for 102 inoperable brain metastases. The primary tumor sites included non-small cell lung carcinoma (n = 24), renal cell carcinoma (n = 14), melanoma (skin) (n = 14), colorectal carcinoma (n = 6), carcinoma of unknown primary (n = 4), and others (n = 7). Eleven patients were treated for relapse after surgery or after conventional whole-brain irradiation. The doses at the isocenter varied from 15-50 Gy (mean, 21.5 Gy). Ten patients with multiple metastases received a planned combination of whole-brain irradiation plus a single boost of 15 Gy. The median survival time for the entire group was 6 months, with a 1-year-survival of 28.3%. Factors associated with significant improvement of survival were brain metastases without other metastatic disease and good response to radiation therapy. Five of 22 patients (22.9%) with metastases located only in the brain survived longer than 2 years. An improvement in neurologic function was found in 81% within a period of 3 months. With imaging techniques, complete remission was found in 20%, partial remission in 35%, stable disease in 40%, and relapse in 5%. The authors concluded that radiosurgery is an effective and safe therapy for brain metastases. It can be applied as primary treatment, as boost in combination with whole-brain irradiation, or as treatment for patients with relapse in a previously irradiated field.

Brain metastases from transitional cell carcinoma of urinary bladder

Of 293 patients with transitional cell carcinoma of the bladder seen at our institution between April 1977 and December 1987, 9 patients were found to have brain metastasis. Seven of 9 patients were found to have a solitary brain lesion, and in 4 of these, no other site of metastatic disease was identified. Five patients received palliative whole brain irradiation, 3,000 cGy in 10 fractions, due to the presence of multiple lesions of the central nervous system (CNS) or metastases to other sites. The average survival for this group was seven weeks. One patient with a solitary brain metastasis and no other documented metastatic site was hospitalized at another institution, and was managed expectantly receiving only parenteral steroid therapy and survived four weeks. Three patients with solitary lesions and no evidence of other metastatic sites were treated with a combined surgical and radio therapeutic approach receiving 4,000–5,000 cGy to the lesion site postoperatively. The average survival of that group was twenty-nine months, with one five-year survivor and 1 patient with no evidence of disease fourteen months after treatment. It appears that survival is longer in those patients with solitary lesions, perhaps due, at least in part to a more aggressive therapeutic approach.

Accuracy and Interobserver Variation in the Interpretation of Computed Tomography in Solitary Brain Lesions

The clinical data and computed tomographic findings of 64 patients with solitary supratentorial brain lesions were presented to two panels of six experienced clinicians. The diagnoses predicted by these clinicians were compared with each other (interobserver variation) and with the definite diagnosis, which in almost all cases was based on histologic examination of the involved tissue (validity of predicted diagnosis). The interobserver agreement was only moderate. The predicted diagnoses agreed with the definite diagnoses in only 57% of cases. A high number of errors were made in distinguishing between high-grade and low-grade glioma and between high-grade glioma and cerebral metastasis, and in the detection of primary cerebral lymphoma. Possible implications of these findings for clinical practice are discussed.

Interobserver variation and accuracy in the interpretation of computer tomography in solitary supratentorial brain lesions : Scientific meeting of the Netherlands Society of Neurology, held in Amsterdam, 22nd of April 1989

The scalp recorded somatosensory evoked potentials (SSEP) following the stimulation of lower extremity nerve (tibial nerve) consists of P17, P24, P31, N35, N37 and P40. Accumulating evidences suggest that the far-field potentials of P17 and P31 arise from the distal portion of the sacral plexus and brainstem, respectively. These correspond to P9 and P14 of the median nerve SSEPs, respectively. The spinal potential of N23 is equivalent to the N13 cervical potential of the median nerve SSEP. N35 recorded from the ipsilateral hemisphere is analogous to N18 of the median nerve. Paradoxically lateralized P40 is the primary positivity generated at the mesial cortical surface, and it more likely corresponds to P26 of the median nerve SSEP. Thus, the first cortical potential corresponding to N20 is probably a small and inconsistent N37 recorded on the contralateral hemisphere.The somatosensory evoked potentials (SSEP) components of lower extremity nerve stimulation should have comparable components with those of upper extremity nerve SSEP. However, neuroanatomical substrates of lower extremity SSEP has been less well explored and delineated as compared with those of upper extremity SSEP. This is because the recording of lower extremity SSEPs from the scalp or from the spine is technically more difficult and the waveforms are less consistent and more individually variable compared with upper extremity SSEPs. Cervical N13, scalp-recorded P14, N18, and N20 of upper extremity SSEPs are all consistently recordable (obligatory) components, whereas the corresponding potentials of lumbar N23 and scalp P31, N35, and N37, respectively, are not necessarily obligatory components. Recording far-field potentials of P9, P11, P13 and P14 after upper extremity nerve stimulation is relatively easy and can be readily applied to the clinical patients, but recording of the corresponding far-field potentials for lower extremity SSEPs is far more difficult and practically impossible to apply routinely to clinical patients.In this communication, we discuss the neuroanatomical substrate and topographies of lower extremity SSEP comparing with those of upper extremity SSEP.

Expanded High Iodine Dose in Computed Cranial Tomography: A Preliminary Report

Fifty patients undergoing cranial CT had expanded-high-iodine-dose (EHID) scans. The EHID was given either as an additional bolus dose (37--40 g iodine) after a routine infusion contrast scan (42.3 g), or as a continuous infusion (total 74--80 g). Diseases presented include primary and metastatic neoplasm, pituitary neoplasm, and demyelinating disease. The results suggest that the primary usefulness of the EHID is in (a) detecting multiple rather than solitary brain lesions, (b) the definitive demonstration of an equivocal area of abnormal enhancement, and (c) differentiating solid histologically microcystic from frankly macrocystic neoplasms.