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	:A Case Of  Multiple  Lung Carcinoma In A Man With Multiple Brain  Metastasis
Approach to Patient
Hulagu Kaptan*, Ender K�ktekir*,*,Hakan Karabal1*, G�khan Akdemir*


A Case Of  Multiple  Lung Carcinoma In A Man With Multiple Brain  Metastasis
Approach to Patient


H�lag� KAPTAN, MD
Assoc. Prof
Department of Neurosurgery, 
Selcuk University,  Medical Faculty, 
Konya, Turkey 
E-mail: HYPERLINK "mailto:hulagukaptan@yahoo.com" hulagukaptan@yahoo.com
Tel: +90 505 398 87 02

Acknowledgments: We would like to thank Dr. P1nar Karabal1 (Selcuk University Faculty of Medicine Department of Pathology, Konya, Turkey) and  Dr. Fahri Ren�ber  Dr. Ali Mutlukan (Selcuk University, Medical School, Department of Neurosurgery, Konya- Turkey) for valuable scientific input during manuscript preparation.


A Case Of  Multiple  Lung Carcinoma In A Man With Multiple Brain  Metastasis
Approach to Patient

Abstract
Case report 
We report a case of lung cancer with multiple metastases to the brain A 55-year-old man suffered onset severe cough and dyspnea.  He had no history of any systemic disease . 
Standard blood work-up was normal.  
Computed tomographic and bronchoscopic biopsy identified an asymptomatic primary pulmonary  Large cell neuroendocrine carcinoma in the left upper lobe of the lungs and - Less differentiated squamous cell carcinoma right upper lobe of the lungs. He also received chemotherapy and  radiation therapy to treat the primary lung cancer.
Magnetic resonance imaging of the brain revealed multiple intracranial tumors. It showing; 3 cm metastatic mass in left temporal  lobe  and  3,5 cm  metastatic mass in right frontal  lobe. There were no metastatic findings in any other organs.
The patient  firstly; underwent a  right frontotemporal approach with total microsurgical resection and after time underwent a  left  temporal approach with total microsurgical resection .  He made good recovery and discharged.
Key Words: Lung Carcinoma, Brain  Metastasis, Multiple, Approach to Patient

Acknowledgments: We would like to thank Dr. P1nar Karabal1 (Selcuk University Faculty of Medicine Department of Pathology, Konya, Turkey) and  Dr. Fahri Ren�ber , Dr. Ali Mutlukan (Selcuk University, Medical School, Department of Neurosurgery, Konya- Turkey) for valuable scientific input during manuscript preparation


Introduction:
Brain metastases are a common mode of general dissemination of lung cancer .
The incidence of brain metastases in the initial staging of patients with primary lung cancer has been reported to be between 12% and 18%of patients.(1) Causing significant morbidity and mortality.
A few selected patients with solitary brain metastasis only and good prognosis may be indicated for surgical resection. Radiotherapy is the mainstay of the palliative  modality in patients with solid tumor with brain metastases. Whole-brain radiation allows for safe treatment over large areas of the brain at a low daily dose to preferentially damage cancer
cells (2,3)
Several studies have demonstrated that chemotherapy induced regression of intracranial secondary lesions.(4)
Case Presentation:
We report a case of lung cancer with multiple metastases to the brain A 75-year-old man suffered onset severe cough and dyspnea.  He had no history of any systemic disease . 
Standard blood work-up was normal.  In case;  lung ca patients with synchronous multiple metastases to the brain alone who received chemotherapy, with concurrent radiotherapy to the brain and also to the thoracic lesions, resulting in mid-term survival, of more than 1 years. Chest Computed tomographic showing;The anterior segment of the upper lobe of the left lung, 7x5, 5 cm size irregular lobulated contoured mass is limited.Right parahilar region show significant mass formation and elongation showing the right upper lobe apical segment of the solid is linear and nodular densities. (Figure1) Bronchoscopic biopsy identified a  Large cell neuroendocrine carcinoma in the left upper lobe of the lungs and - Less differentiated squamous cell carcinoma right upper lobe of the lungs. He also received chemotherapy and  radiation therapy to treat the primary lung cancer. 
For Lung Carsinoma;Chemotherapy, consisting of cisplatin (40mg/m2) and docetaxel (40mg/m2), was administered on days 1 and 8, with the drugs being given separately, and the chemotherapy was repeated every 4 weeks for up to three cycles. 
In Magnetic resonance imaging(MRI);   3x3,5 cm demarcated  solitary-cystic metastatic mass in right frontal  lobe.(Figure 2) The patient  firstly; underwent a  right frontotemporal approach with total microsurgical resection. Subsequently, radiotherapy was performed for the left brain lesion. Whole-brain irradiation (2 Gy/day; total, 36 Gy) and thoracic irradiation (2Gy/day; total, 60Gy) were started on days 1 and 29, respectively.  One month after the radiotherapy, the brain lesion was not changed by MRI. 
He had developed progressively herniation ; general condition deteriorated and consciousness disturbance. MRI scans of the brain demonstrated a 2,5x 3 cm well demarcated  solitary-cystic metastatic mass in  left temporal  lobe(Figure-2). He underwent emergency surgery. Left  temporal approach with total microsurgical resection was performed and metastatic ca was diagnosed. Histological examination of the tumor specimen taken from the central part of the tumor revealed metastasis. There were no metastatic findings in any other organs. He made good recovery and discharged. Our patient has been successfully treated .
The patient recognizes a multidisciplinary approach (Department of Medical Oncology, Neurosurgery, Radition Oncology ,  Thoracic Surgery  and Thoracic Diseases)  outweigh the risks. patients can take the wrong decisions. The patient does not expect a long life. For this reason, the patient refuses surgery. Surgeons, taking into account medico-legal problems. Surgical treatment also gets late. 
Discussion:
The patient described here in presented an atypical clinical course-approach to patient�s and imaging findings for multiple metastatic brain tumor of multiple lung cancer. this is the first case in the literature, different pathological cases with a diagnosis of lung cancer and multiple brain metastases.
A literature review suggested that lung carcinoma was the most frequent primary lesion responsible. CT and/or MRI has detected such lesions; which would previously have been subclinical (5) The addition of radiotherapy to surgery did not have an impact on survival but decreased recurrence from 70% to 18%.(8) In our case; after the radiotherapy, the brain lesion was not changed.. 
The chemotherapy, with concurrent radiotherapy  should be given to those  patients with brain metastases only in whom a significant survival benefit can be expected. Recurrent or new lesions in other organs have not been observed.(6,7) This treatment is expected to prolong survival, not only by improving tumor control in the brain and thorax but also by preventing or delaying the emergence of metastatic disease at sites other than the brain.(8)
methods of treatment are very important. Due to today's circumstances; approach to the treatment of the patient is also important.
Conclusion
We consider important that preoperative evaluation and intensive talk about with condition of patient ; for facilitate early  operable of brain metastases in patients .We aren�t thinking about medico-legal problems;we have to take the initiative. 
So, Many  patients with  brain metastases were cured or had a well-maintained quality of life for a longer period.

References:
1.Mintz BJ, Tuhrim S, Alexander S, et al. Intracranial metastases in the initial staging of bronchogenic carcinoma. Chest 1984; 86:850�853
2. Taimur S, Edelman MJ (2003) Treatment options for brain metastases in patients with non-small-cell lung cancer. Curr Oncol
Rep 5:342�346
3. HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=Lamm%20AF%5BAuthor%5D&cauthor=true&cauthor_uid=23056973" Lamm AF,  HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=Elaimy%20AL%5BAuthor%5D&cauthor=true&cauthor_uid=23056973" Elaimy AL,  HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=Mackay%20AR%5BAuthor%5D&cauthor=true&cauthor_uid=23056973" Mackay AR,  HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=Fairbanks%20RK%5BAuthor%5D&cauthor=true&cauthor_uid=23056973" Fairbanks RK,  HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=Demakas%20JJ%5BAuthor%5D&cauthor=true&cauthor_uid=23056973" Demakas JJ,  HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=Cooke%20BS%5BAuthor%5D&cauthor=true&cauthor_uid=23056973" Cooke BS,  HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=Lee%20CM%5BAuthor%5D&cauthor=true&cauthor_uid=23056973" Lee CM,  HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=Taylor%20BS%5BAuthor%5D&cauthor=true&cauthor_uid=23056973" Taylor BS,  HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=Lamoreaux%20WT%5BAuthor%5D&cauthor=true&cauthor_uid=23056973" Lamoreaux WT. Long-Term Survival of a Patient with Brainstem and Recurrent Brain Metastasis from Stage IV Nonsmall Cell Lung Cancer Treated with Multiple Gamma Knife Radiosurgeries and Craniotomies: A Case Report and Review of the Literature.  HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=Long-TermSurvival%20of%20a%20Patient%20with%20Brainstemand%20Recurrent%20BrainMetastasis%20from%20Stage%20IV%20Nonsmall%20Cell%20Lung%20Cancer" \o "Case reports in oncological medicine." Case Rep Oncol Med. 2012;2012:621641. doi: 10.1155/2012/621641. Epub 2012 Sep 29.
4. Malacarne P, Santini A, Maestri A (1996) Response of brain metastases from lung cancer to systemic chemotherapy with carboplatin and etoposide. Oncology 53:210�213
5.Bruner, J.M., Tien, R.D.: Secondary tumors. In: Bigner DD, McLendon RE, Bruner JM (eds). Russell and Rubinstein�s Pathology of Tumors of the Nervous System, 6th edn, Vol. 2. London: Arnold, 1998; 419-450.
6.Ryan G, Ball D, Bishop J, et al. (1994) A phase II study of combined chemotherapy and radiation for brain metastases from nonsmall- cell lung carcinoma of the lung. Lung Cancer 11 (Suppl1):176
7.Quantin X, Khial F, Reme-Saumon M, et al. Concomitant brain radiotherapy and vinorelbine-ifosfamide-cisplatin chemotherapy in brain metastases of non-small cell lung cancer. Lung Cancer 1999;26:35�39
8.  HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=Harita%20S%5BAuthor%5D&cauthor=true&cauthor_uid=15729604" Harita S, �������		(	F	H	J	N	�	�	




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Figures:


Figure 1: Chest computed tomography imaging on admission showed the primary lesion in the left upper lobe.


Figure 2: T1-weighted  and T2-weighted images in the transaxial-coronal  plane showing solitary-cystic mass .






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