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Brain metastasis of choriocarcinoma
Brain Metastast's of Chofic :arcinoma Tatsuya Koba,~mshi, M.D., ~;~shihisa Kida, M~D., Jun Yoshida, M.D.. Naoki Shibuya, M.D. and Naoki Kageyama, M.D.
TwenW-four ~tients with h~tokgicall¥ verified brain meosmsis of chofi~arcinoma were anal¥:ed re~rding autopsy and ope~dve findi~4s~ si~s and symptoms~diagnosis, me~od of t~atment, and prognosis. ~ e autopsy incidence of b~in metastasis was 66.7% in patients with chori~arcinoma, aM the p~dominance d single b~in lesions was ¢onfi~ed. Most of the m e t ~ t a ~ lesions g ~ hemorrha#c. ~ e hemorrhages were int=tumoraL peritumoml, an&*or sule~raehnoid. ~ e s e findings we~, well co~lated ~ ~ e fin~ngs on computM ~mc~. graphic (~) s~ns and the acute ~ s e t wi~ rapM p sion of ms. The histo~ of molar prc~ancy, measu~ments of urinary chorion~ g, nadotmpin, and findings on ~ ~ans we~ d tic. Surgi~l ~moval of the lesion followc~ by chemothe~py combined with irradiation is the treatment of choice in ~tients with p~ressive neu I deterioration in whom chemotherapy abne is ineffective.
Materials and Meth~ At Nagoya Unive~ity Hospital. 122 patients with cho+ ric~arcinoma were treated ~tween 1965 and 1977. Eighty-raven cases were histologically verified, and 3 5 were diagno~d clinically. Of the 35 patients diagnosed clinically, 28 (~%) ate still alive and their d i ~ is in remission. Of the 87 patients with histological verification. 54 (6L 1%) are still alive and in feminism, havil~g~nderg~me ~ : ~ t i n n combined wi~ ¢hem~thempy, Thirty-thr~,e M the 87 patients d i ~ (mortality ~te, 38%) ~:cat~e of advanced p ~ e / ~ i o n of the dise~. All undee~ent areaway. and brain mera~a~is ~ s confimed in 22. ~ u s , the freq~ncy of me s to the rental ne~'ous s~'stem shown b~' autopsy ctmld b~ e~timated to M as high as ~ 7 % {22 d 33L while the oeemil incidence was 27.6% (24 {ff 87). Antony findings~ signs and s~,mptoms, diagnmi~ treat~ menL and pn}gm~siswere studied in 24 g~tients with brain metastasis of choricmarcinoma, including 2 ~urviv~m,.
KobaDstru T. Kid~ Y. "i~hi&l J, ~itmya N, K ~ m ~ N: Brain m~a~am ~ffchortocareinom~,
8=~ Neut.! I7 3 9 ~ 3 . I982
It is well rec~ni:ed that the prognosis of chori~arcinoma h ~ ~u.~en ma#~ed|y improved since the intr~ction of cher~otheraF~utic agents {9, 12~ 13]. Ho~.ever. one.dhiM of ~tients with chorkmarcinoma still die ~om this m~ig*. nancy, the most common cause M death ~ing brain m e t a s ~ i s I9]. Recent ~vances in diagnostic procedures and o~mtive technMuc~ in neur~uno,er~' have made p~-siMe early detection [8)and a more favorable prcgnmis in the dis¢~:~ [16]. ~ e im~rtant role M computed tom(graphic (C~) scan~ ning in the early deletion and mana~ment M brain metastasis is strewed. We shall di~:uss the indicatiot~ for surgical n'~tment of brain metastasis based on the findir~s at autopsy and ~1~e~tion at Nago~ Unive~ity Hospital.
Med~i~. Nag,ra. Jae~n~ .
Unt~'enity~ho.a! M M ~ i n ¢ , 65
,¢~,
Results Autopsy findings in the 22 patients revealed that the hmg was the m~t common site of me~static choric~arcim~ma other than the b~in (all patients had a metastatic p~lmo~ nary I~ion}, followcxtby the liver {12 ca~:s~ 54~5%L kidney {9 c ~ , 40.~6), spleen {5 ca~s~ 227%L ~-zlvis {4 c ~ , l&l%), intestine {3 ca~_.% tL6%), colon (3 ca~s, I3.6%L and urknar'¢blMdc~ {2 ca~:s, 9. t%L Among the 24 paxieats with b~in metas~asis~a single l~ion was f¢~nd in 16 {{~d%} and multiple lesions in 8 (3L3%} The laotian {ff thc~ lesions was the ~rieral lobe (10 cases}. tem~ml (5 ca~es), ~c¢ipital (4 cams), frontal {3 cases). cerebellum (4 cases), and b~in stem {I case). ~ e metastatic l~ions were nu~tly s#erical in shaft. and 15 M 24 patients {62A%) had hemo~hage in the form of int~cembml and perit'art~l hemam~r~s or sub. a~chnoid hemorrhage (Fig. tL Micro~c~ic examination of the met~.-tatic ~ s s ~v~1¢4 a central necrosis and ~ f i # e = l layer M mnmr cells ~ i a m a with intra I and ~rivamoral hemorrhagic fc*:i (Fig. 2). All ~tients were women ~tw~,n 23 and ~ years of a ~ { a v e ~ , age. 35.5 years), and 16 patien~ {{6.7%) had a hgto~' of a molar pr~ancyo initial si~s and symptom~are s h o ~ in Table t. Su~en onset M he~M~h~ and convub siot~a were ~ e mc, t t init~l symptow~, follow~ by hemi~, ~n~r¢ dhturbance, and ¢onfla~ion. ~ m ~ n
~3019/8~'060}95.~${}1,25 © 19~ by Little, Brownand
{Ir~) 395
$96 S~r~ica~Ne~m~l~r V~d 17 ~",~6j~me loS2
,ign-, a~d ~,.mp~,m~ |~md during the dinica~ o.~m~" ar~ d~,wn m Table 2~ Sigr~ ~ff i~ctea~'d intracrania| prc:-e.t~te theadache, nausea, and vomiting) ~e~c the tn{~*~L,~4ucnt. Hemiparc~i a~d convul,ion, wetc c~mmo~. Papilledema ,rod ~o;,, of cons¢ioumeR,;o,lC/~r¢~ in 6 m d 4 patients, re~ tI~¢~E: xLS)
~*e c|imca| diagm~is M b~m~ me~aua~iswa.~made with~ ~,l ,hf~c~hv wh,m a patie~t ~ d had a m o l a ~v~m;mcy ~r a prt,vk~> d+agn~+i~o(chotk~arcim,ma+ and had increa~:d ir'/trac~,~niat pr{+~ut¢ ot neu~okgieal sg~pu~m~+ Choti{mic .~madot~opit~was m,ea~ut~di~ ~|~e~i~e in most M the pa~ tients ~hil¢ their i|lne~ wa~ i~ remi~ion~ and incree~,e, correlated w¢|| with recurrence ~, metastasis, The lo,:a|i~tam ~f intracmnia| k~,k~n,had ~t-n id{~tifi~| ptevk~ly b}* ek*ctr~'ncephaloK~ph*'~ ~adioi~tore .,
simms a higher de,~sit~~i 30 va 40 EMt ~3nirs). )d~t ~ff the k~ions w~:re enhanced a(ter a~mini~tmtion ~f e~mtL~t m~Miem~ Re~trding treatment a~d plc*gmf~i~,Ibx 24 svJdv ~6ents were ¢ l ~ i ~ d in~o two ~oup~: neiltt~u,*giea| W~Kedures ~:re carried ~*t~tin 9 ~iient~; {Table 3) and chel~he~lpy ~*it~ meth~trexat,: alad aet!~y~m~zin D in 15 {Tab|e 4), ~ e ~rgica| group was divi&~ inU~ t~x~ s u b ~ m ~ accot~ding m the kind of ¢ombind d~e~apy administ&od. Paaents I ~ o u g h 5 were by surgical t r ~ t m ~ t and chemothempy ~ith methotrexale and acrinomycin O. dent 6 under~'ent ~ I y m~ee~.) I~ d'~is p, total re.
+K~+bava4++e+ ah Mt+la>tld¢ Chofioc+fcm~+m, of lhe Brain 397
moral ~+f ~he recta+retie le+hm~ was &me in 3 paticms+ pania| termmd in |+ and d+~omprc~++iveprocedures in 2+ Patients 7, 8, and 9 were t~eatcd by rata| removal of the le+ons and by a c++mbinztkm of chemo~hemp+; with ~wo agents and whole brain i~diation under a s~chedukxtp~xv
Table I+ Ini+ial Siam and ~vmrt{}m+ Si+g+>and SFmptom+
+N~+~+ Cams
C~+n+i++km Senm+rydi+mrb+mee+ ||emip~i+e+i+ ¢.[hmv+~ilsh+~ I [ead;~he
+ 2 4 $ 12
TaNe 2~ Simn+~and Svmpt+m%dtmnR ( ; ~ e
of Ilh~c~,~
Si~n~ and S~,mptom~
No+ of (a~es
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3 4
( 2+mh~,i~m
4
gram+ The intel~¢al from diag+m+~i+~ff ch~nitmamimmu~ t+ evi+ donee tel"brain mctas+a+is and Ihe survival time a(ter +Ieat+ meal wcrc c~+mpared i~ the two gnmp++ The Inciln Jitl+iitilln k<~vea ink/a| diagnt,.qs and evidence of mctastasi~ was 129 montl~ in d~e chemt,therapy gr~mp and 14+7 +mind,s in the surRical Rroup+ The f~+sto~rative st~rvival of 7 pat tients in the ~,urgicaigroup (excluding 2 sumqving patients) wa~ I019 months+ while the inten+a[ from brain metastasis to death in the t:hemothcmp}' gamp was 4+5 months+ From another vietwoin~+ the mean pmtop++'rative survival of the 3 Nrienls +m+tt+d under +he ~heduie program (Patients 7 thmueh 9) was more dtan 27+3 months+ while that of the other 6 g+~ticnts ttcatcxl sureirall+¢ was comparable to that of the glee>tiptreated tm|g bY ¢he/m+therapy+
I
Papi|l~dema C~mvuhi~m Hemif,ace+~is Hea&~he
7 | I4 I4
ll|ustrativc Cm;e Reports Patient 8 A 3l+v~mr+oM +roman had had a m~+kar p+c+mancv in Jammr+v+ 1974 (Fig+ 3)+ NO chockmp+ we+ made umii INcem~,r 23+ 1977, when +he patimt complained of mvem
TaNe L Summa~+~d Su+u++dlV T+catcd (2a~c,, o+ Mc
N++
A~v
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M+~+++
Pt++,~m+m+ ~m~++re S+m~+m,
+M+~+,+++++++
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ira+4
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t+
b+|+i+¢+l+Pm+k+2
4
++4
Lhem+~+e+mh+~+
¢~rA
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+it
+
He++d,+¢~e+ ++m~+~++++
+
+
7
44
+
P ~ + ~ h ¢ + ~x~++¢+++
++
+4
R hem+p~e~+
CPA, VP++ ++L~+7,+ CPA/+;O&~
'+
26
+
P~eh+
0
14
%=~I ++m,+~+~
~a|++++
t+~+~++al
400
Surgical Neurology \'ol 17 No ¢~Jtmc l~S2
Fig. 4. Patient 8. Plain C T scans shouting r,~:md, high-&rtsi~y ma.sses in (A) the t~'ft l~rictal t,,be mut (B~' the r/d~ ctvcR'//ar h,..mi.~ht"r~.-. St'yen m~mrhs after crani,,t~,n~. "a neu' high-densiz, T~u*.~u,i~h c~'nrral lou,d¢Tuiry area is f~,u,ut in lb : left frcnlral lobe ( C). u.hich dis~tppt'are~f with cheTn,,rh,.vap?" and irradii~i~m ( D).
l
l
IOL
IO~ IL n|)
t I 9t It i~I
1 ~tcQ
neu~x~k~icaI sie~s and ago with the- ¢K-~cteri~k C~ findin~:s. ~'~om a d ~c ~ia~ of view. it ~h~id ~: ~ t e d tE~t the p~tWnts were M} n 23 a~d ~ v e ~ o|d {average a~e~ 35.5 ~-t~} Five ~t/ems ~:te ~ o n ~ the chdd ag~.'~ ~ g i~ a $°~aBger age* dismbudc~ ~ a ~ that with ofl~er metastatic bgain tm.~.:~ |61. The clinical diagn~**t~,was not di(ficuh if the paticmt had a hi~. tow of molar pregnancr or a b ~ r n ~ l vaginal b l t ~ i ~ with sudde~ onset of neumh~ieal ~i~,m~, ~ach aS hncteas¢~J in* uacmnial ptessute~ ¢onv~Eions, and hemiplegia i i ~ 15, |9L Ahhou~h it' h a k * n know~ that only" 10% e£ h,;datid moles progte~-; to ehork~arci~ma {16L manT patients with choriocarcL~ma have a h ~ a r y d a mu~r ey, a~ in {~t varies~ Jr is i nt fog patiems with tem~sit*n ~ c}~i~:arctnoma to have ~tit>/tic checks ~ff the I . n ~ b~" x-ray ~ami~atRm arm ~ ehorionic topin lewclin the ~de~e ~lr ~ m ~ ~ s is ¢~anclusive ~,ith the a,ddb {iOn of evi&nee of |esi{ms o~ C ~ aanS [8, 1| J a~d CM~O" nit in die t%M {2, 17L aI e ~ c g ~ ed ~topic &o,i~arcinoma |7, It} and n tional &ofi(~ateinoma have been |161. C)nl5~ a *q:w ca~ s c~mccming the treatment of metastatk: chor'k~at¢in<~na M the brain have ed ~4, 7. IA 16] and there h a k~aen ~me" con~cr,'ets}" a ~ n t ~ e a iate t h e r a ~ t i e appvaach m these ~esions~ ~}me {7, 16t ins/st ur~}n surgical | t~*gne In|on followed bF &cmotherapy aM ir~adiatkm, ~.hile otM~ s~-pport chemoth~:vpy with or wkhout imdiatior, [{, 13, 19] It is •~elI that ~he advent of ehemothe~pV ~ t l ' ¢ ~ vanced ~he t of ~mc~atie brain w~ r~¢ easi|v ~ c o m # s h ~ g'~eW e n t d ~ ; and {4) 5 o~er ~ t i e n ~ { the ehild~agng a ~ ) were i in the e~p~ g ~ p , who of age were 1 ~ tol~nt d ~e Two ~ d e n ~ (Patient~ 8 and 9} we~ s b¢ with~at of n¢;'~ I ddci~, g~ 24 ~ d 9 are d intere~st tn evaI~ting the indieatio~2; for d t ¢ me In Patient 8, two metastatic l~iora, ~-~e in the dght cerd:~|I~ hemi a~ in the
l & Dtieml Io~. were &~md b.; ~ ~m the &v of the suddm~ o ~ t of ~eu ~ ~ e t e was M~> a I ~ e t~c l~ion in the, right l~g. ~ e fi~ c~oice of therapy g ~ | ! d the I1~ k~ic~ f ~ cause of the |ire-threatening ~ d i t i o m ~ e patient ~ s rely well ¢onm~|k~ by d ~ t : ~ h e ~ p y ~*J thor~otom$'. !t is also intet'es~ing that the hi£h*&_nsiB" Ic* shm in the parietal I o ~ had on ~,,a~c~ CT g a ~ fo|towing Chemothe~p~. M~eover. a ~e~' metastatic l~ion w~ fevand in the 1 ~ froma| | o ~ and wa~ as~:
J+ml+?l "+tl+i+~ +++l+~ +;) |nitd
+++m.+~h++ml+pu++ +>+++~+~+>++++,+++<+~++~1++q+ ++ p+++~+dp+it+++ :~+m ~p+~|~v.+~+++++++~|+ +is>,pro++++++o +~d++~at|+p+ ;+~++m+3+++'~.| +qI +~+|I++++~+l +~m |+~lm ++|.l+..~+ +s ;~t+,~s+pW+|+p+ ++++l+ld le3m+1 + e +++l.h ,+qi j o u++~WlllmllX++ +It+iN ,t+ I1,+,+ ++++ l+tlllt It/IIJG pill +}%~+1~l "7+t1!10 :+lit tl+ ltl+ltlO;+ lt i+|t+llo}++ltlt~+~ ++ ++m+t|lti+ ++ill lualJ 0 at|l tt+ tl+mo+~ t++ ;~)tio+l++ ++~+ltI ~lti~+ll~+t/,+~~+~til++ tlt~ill~tl}ll++l~l,~p lllJ+JltO ~ltll*lll'.~ ltl{~tlld~+l;~;++
d'+F',~+P P|+~+~p ++q+ jl +~lml+++++~+~l+l+itml+ ++~tl+ ;++i PlP+°tP +~+.+++lap+++l++m++lWq .~:~eq,++ t++~+++~+~:+.~+~l+,~l++p:++i+++d +it,+ m++a++~l|,llq+ y+ ++mk++~ +t++++~t~+.++xTl+m+mw.+++ p~++ +Ira+. /+++my+++m p~+~<+bl+d ++lull} s+ emom+!+~Jem+!++tpj o ++~el +~+ill +ill++ p+ ++>ml++iJ+~bti+alll .++:l~+~tlat++a++tla+l++++ +++t~ ++l;+m ir+,b++++ +~+ +oi¢+~mx~+ptm +u;sv++,+eqc+~+~q +;+dt+dS+tLL
~1oN le!JO~!lr~
~01+ ~+++~I+~q~ ~ +'~+u+++++~+i~++q~+ ~!~+~l+~l~ ~+~'~ +~l~++~i~++~
TwenW-four ~tients with h~tokgicall¥ verified brain meosmsis of chofi~arcinoma were anal¥:ed re~rding autopsy and ope~dve findi~4s~ si~s and symptoms~diagnosis, me~od of t~atment, and prognosis. ~ e autopsy incidence of b~in metastasis was 66.7% in patients with chori~arcinoma, aM the p~dominance d single b~in lesions was ¢onfi~ed. Most of the m e t ~ t a ~ lesions g ~ hemorrha#c. ~ e hemorrhages were int=tumoraL peritumoml, an&*or sule~raehnoid. ~ e s e findings we~, well co~lated ~ ~ e fin~ngs on computM ~mc~. graphic (~) s~ns and the acute ~ s e t wi~ rapM p sion of ms. The histo~ of molar prc~ancy, measu~ments of urinary chorion~ g, nadotmpin, and findings on ~ ~ans we~ d tic. Surgi~l ~moval of the lesion followc~ by chemothe~py combined with irradiation is the treatment of choice in ~tients with p~ressive neu I deterioration in whom chemotherapy abne is ineffective.
Materials and Meth~ At Nagoya Unive~ity Hospital. 122 patients with cho+ ric~arcinoma were treated ~tween 1965 and 1977. Eighty-raven cases were histologically verified, and 3 5 were diagno~d clinically. Of the 35 patients diagnosed clinically, 28 (~%) ate still alive and their d i ~ is in remission. Of the 87 patients with histological verification. 54 (6L 1%) are still alive and in feminism, havil~g~nderg~me ~ : ~ t i n n combined wi~ ¢hem~thempy, Thirty-thr~,e M the 87 patients d i ~ (mortality ~te, 38%) ~:cat~e of advanced p ~ e / ~ i o n of the dise~. All undee~ent areaway. and brain mera~a~is ~ s confimed in 22. ~ u s , the freq~ncy of me s to the rental ne~'ous s~'stem shown b~' autopsy ctmld b~ e~timated to M as high as ~ 7 % {22 d 33L while the oeemil incidence was 27.6% (24 {ff 87). Antony findings~ signs and s~,mptoms, diagnmi~ treat~ menL and pn}gm~siswere studied in 24 g~tients with brain metastasis of choricmarcinoma, including 2 ~urviv~m,.
KobaDstru T. Kid~ Y. "i~hi&l J, ~itmya N, K ~ m ~ N: Brain m~a~am ~ffchortocareinom~,
8=~ Neut.! I7 3 9 ~ 3 . I982
It is well rec~ni:ed that the prognosis of chori~arcinoma h ~ ~u.~en ma#~ed|y improved since the intr~ction of cher~otheraF~utic agents {9, 12~ 13]. Ho~.ever. one.dhiM of ~tients with chorkmarcinoma still die ~om this m~ig*. nancy, the most common cause M death ~ing brain m e t a s ~ i s I9]. Recent ~vances in diagnostic procedures and o~mtive technMuc~ in neur~uno,er~' have made p~-siMe early detection [8)and a more favorable prcgnmis in the dis¢~:~ [16]. ~ e im~rtant role M computed tom(graphic (C~) scan~ ning in the early deletion and mana~ment M brain metastasis is strewed. We shall di~:uss the indicatiot~ for surgical n'~tment of brain metastasis based on the findir~s at autopsy and ~1~e~tion at Nago~ Unive~ity Hospital.
Med~i~. Nag,ra. Jae~n~ .
Unt~'enity~ho.a! M M ~ i n ¢ , 65
,¢~,
Results Autopsy findings in the 22 patients revealed that the hmg was the m~t common site of me~static choric~arcim~ma other than the b~in (all patients had a metastatic p~lmo~ nary I~ion}, followcxtby the liver {12 ca~:s~ 54~5%L kidney {9 c ~ , 40.~6), spleen {5 ca~s~ 227%L ~-zlvis {4 c ~ , l&l%), intestine {3 ca~_.% tL6%), colon (3 ca~s, I3.6%L and urknar'¢blMdc~ {2 ca~:s, 9. t%L Among the 24 paxieats with b~in metas~asis~a single l~ion was f¢~nd in 16 {{~d%} and multiple lesions in 8 (3L3%} The laotian {ff thc~ lesions was the ~rieral lobe (10 cases}. tem~ml (5 ca~es), ~c¢ipital (4 cams), frontal {3 cases). cerebellum (4 cases), and b~in stem {I case). ~ e metastatic l~ions were nu~tly s#erical in shaft. and 15 M 24 patients {62A%) had hemo~hage in the form of int~cembml and perit'art~l hemam~r~s or sub. a~chnoid hemorrhage (Fig. tL Micro~c~ic examination of the met~.-tatic ~ s s ~v~1¢4 a central necrosis and ~ f i # e = l layer M mnmr cells ~ i a m a with intra I and ~rivamoral hemorrhagic fc*:i (Fig. 2). All ~tients were women ~tw~,n 23 and ~ years of a ~ { a v e ~ , age. 35.5 years), and 16 patien~ {{6.7%) had a hgto~' of a molar pr~ancyo initial si~s and symptom~are s h o ~ in Table t. Su~en onset M he~M~h~ and convub siot~a were ~ e mc, t t init~l symptow~, follow~ by hemi~, ~n~r¢ dhturbance, and ¢onfla~ion. ~ m ~ n
~3019/8~'060}95.~${}1,25 © 19~ by Little, Brownand
{Ir~) 395
$96 S~r~ica~Ne~m~l~r V~d 17 ~",~6j~me loS2
,ign-, a~d ~,.mp~,m~ |~md during the dinica~ o.~m~" ar~ d~,wn m Table 2~ Sigr~ ~ff i~ctea~'d intracrania| prc:-e.t~te theadache, nausea, and vomiting) ~e~c the tn{~*~L,~4ucnt. Hemiparc~i a~d convul,ion, wetc c~mmo~. Papilledema ,rod ~o;,, of cons¢ioumeR,;o,lC/~r¢~ in 6 m d 4 patients, re~ tI~¢~E: xLS)
~*e c|imca| diagm~is M b~m~ me~aua~iswa.~made with~ ~,l ,hf~c~hv wh,m a patie~t ~ d had a m o l a ~v~m;mcy ~r a prt,vk~> d+agn~+i~o(chotk~arcim,ma+ and had increa~:d ir'/trac~,~niat pr{+~ut¢ ot neu~okgieal sg~pu~m~+ Choti{mic .~madot~opit~was m,ea~ut~di~ ~|~e~i~e in most M the pa~ tients ~hil¢ their i|lne~ wa~ i~ remi~ion~ and incree~,e, correlated w¢|| with recurrence ~, metastasis, The lo,:a|i~tam ~f intracmnia| k~,k~n,had ~t-n id{~tifi~| ptevk~ly b}* ek*ctr~'ncephaloK~ph*'~ ~adioi~tore .,
simms a higher de,~sit~~i 30 va 40 EMt ~3nirs). )d~t ~ff the k~ions w~:re enhanced a(ter a~mini~tmtion ~f e~mtL~t m~Miem~ Re~trding treatment a~d plc*gmf~i~,Ibx 24 svJdv ~6ents were ¢ l ~ i ~ d in~o two ~oup~: neiltt~u,*giea| W~Kedures ~:re carried ~*t~tin 9 ~iient~; {Table 3) and chel~he~lpy ~*it~ meth~trexat,: alad aet!~y~m~zin D in 15 {Tab|e 4), ~ e ~rgica| group was divi&~ inU~ t~x~ s u b ~ m ~ accot~ding m the kind of ¢ombind d~e~apy administ&od. Paaents I ~ o u g h 5 were by surgical t r ~ t m ~ t and chemothempy ~ith methotrexale and acrinomycin O. dent 6 under~'ent ~ I y m~ee~.) I~ d'~is p, total re.
+K~+bava4++e+ ah Mt+la>tld¢ Chofioc+fcm~+m, of lhe Brain 397
moral ~+f ~he recta+retie le+hm~ was &me in 3 paticms+ pania| termmd in |+ and d+~omprc~++iveprocedures in 2+ Patients 7, 8, and 9 were t~eatcd by rata| removal of the le+ons and by a c++mbinztkm of chemo~hemp+; with ~wo agents and whole brain i~diation under a s~chedukxtp~xv
Table I+ Ini+ial Siam and ~vmrt{}m+ Si+g+>and SFmptom+
+N~+~+ Cams
C~+n+i++km Senm+rydi+mrb+mee+ ||emip~i+e+i+ ¢.[hmv+~ilsh+~ I [ead;~he
+ 2 4 $ 12
TaNe 2~ Simn+~and Svmpt+m%dtmnR ( ; ~ e
of Ilh~c~,~
Si~n~ and S~,mptom~
No+ of (a~es
\+e+ t tg~ + Semotv di+tutbances Nau~'a+ vtmfiting
3 4
( 2+mh~,i~m
4
gram+ The intel~¢al from diag+m+~i+~ff ch~nitmamimmu~ t+ evi+ donee tel"brain mctas+a+is and Ihe survival time a(ter +Ieat+ meal wcrc c~+mpared i~ the two gnmp++ The Inciln Jitl+iitilln k<~vea ink/a| diagnt,.qs and evidence of mctastasi~ was 129 montl~ in d~e chemt,therapy gr~mp and 14+7 +mind,s in the surRical Rroup+ The f~+sto~rative st~rvival of 7 pat tients in the ~,urgicaigroup (excluding 2 sumqving patients) wa~ I019 months+ while the inten+a[ from brain metastasis to death in the t:hemothcmp}' gamp was 4+5 months+ From another vietwoin~+ the mean pmtop++'rative survival of the 3 Nrienls +m+tt+d under +he ~heduie program (Patients 7 thmueh 9) was more dtan 27+3 months+ while that of the other 6 g+~ticnts ttcatcxl sureirall+¢ was comparable to that of the glee>tiptreated tm|g bY ¢he/m+therapy+
I
Papi|l~dema C~mvuhi~m Hemif,ace+~is Hea&~he
7 | I4 I4
ll|ustrativc Cm;e Reports Patient 8 A 3l+v~mr+oM +roman had had a m~+kar p+c+mancv in Jammr+v+ 1974 (Fig+ 3)+ NO chockmp+ we+ made umii INcem~,r 23+ 1977, when +he patimt complained of mvem
TaNe L Summa~+~d Su+u++dlV T+catcd (2a~c,, o+ Mc
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400
Surgical Neurology \'ol 17 No ¢~Jtmc l~S2
Fig. 4. Patient 8. Plain C T scans shouting r,~:md, high-&rtsi~y ma.sses in (A) the t~'ft l~rictal t,,be mut (B~' the r/d~ ctvcR'//ar h,..mi.~ht"r~.-. St'yen m~mrhs after crani,,t~,n~. "a neu' high-densiz, T~u*.~u,i~h c~'nrral lou,d¢Tuiry area is f~,u,ut in lb : left frcnlral lobe ( C). u.hich dis~tppt'are~f with cheTn,,rh,.vap?" and irradii~i~m ( D).
l
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neu~x~k~icaI sie~s and ago with the- ¢K-~cteri~k C~ findin~:s. ~'~om a d ~c ~ia~ of view. it ~h~id ~: ~ t e d tE~t the p~tWnts were M} n 23 a~d ~ v e ~ o|d {average a~e~ 35.5 ~-t~} Five ~t/ems ~:te ~ o n ~ the chdd ag~.'~ ~ g i~ a $°~aBger age* dismbudc~ ~ a ~ that with ofl~er metastatic bgain tm.~.:~ |61. The clinical diagn~**t~,was not di(ficuh if the paticmt had a hi~. tow of molar pregnancr or a b ~ r n ~ l vaginal b l t ~ i ~ with sudde~ onset of neumh~ieal ~i~,m~, ~ach aS hncteas¢~J in* uacmnial ptessute~ ¢onv~Eions, and hemiplegia i i ~ 15, |9L Ahhou~h it' h a k * n know~ that only" 10% e£ h,;datid moles progte~-; to ehork~arci~ma {16L manT patients with choriocarcL~ma have a h ~ a r y d a mu~r ey, a~ in {~t varies~ Jr is i nt fog patiems with tem~sit*n ~ c}~i~:arctnoma to have ~tit>/tic checks ~ff the I . n ~ b~" x-ray ~ami~atRm arm ~ ehorionic topin lewclin the ~de~e ~lr ~ m ~ ~ s is ¢~anclusive ~,ith the a,ddb {iOn of evi&nee of |esi{ms o~ C ~ aanS [8, 1| J a~d CM~O" nit in die t%M {2, 17L aI e ~ c g ~ ed ~topic &o,i~arcinoma |7, It} and n tional &ofi(~ateinoma have been |161. C)nl5~ a *q:w ca~ s c~mccming the treatment of metastatk: chor'k~at¢in<~na M the brain have ed ~4, 7. IA 16] and there h a k~aen ~me" con~cr,'ets}" a ~ n t ~ e a iate t h e r a ~ t i e appvaach m these ~esions~ ~}me {7, 16t ins/st ur~}n surgical | t~*gne In|on followed bF &cmotherapy aM ir~adiatkm, ~.hile otM~ s~-pport chemoth~:vpy with or wkhout imdiatior, [{, 13, 19] It is •~elI that ~he advent of ehemothe~pV ~ t l ' ¢ ~ vanced ~he t of ~mc
l & Dtieml Io~. were &~md b.; ~ ~m the &v of the suddm~ o ~ t of ~eu ~ ~ e t e was M~> a I ~ e t~c l~ion in the, right l~g. ~ e fi~ c~oice of therapy g ~ | ! d the I1~ k~ic~ f ~ cause of the |ire-threatening ~ d i t i o m ~ e patient ~ s rely well ¢onm~|k~ by d ~ t : ~ h e ~ p y ~*J thor~otom$'. !t is also intet'es~ing that the hi£h*&_nsiB" Ic* shm in the parietal I o ~ had on ~,,a~c~ CT g a ~ fo|towing Chemothe~p~. M~eover. a ~e~' metastatic l~ion w~ fevand in the 1 ~ froma| | o ~ and wa~ as~:
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+++m.+~h++ml+pu++ +>+++~+~+>++++,+++<+~++~1++q+ ++ p+++~+dp+it+++ :~+m ~p+~|~v.+~+++++++~|+ +is>,pro++++++o +~d++~at|+p+ ;+~++m+3+++'~.| +qI +~+|I++++~+l +~m |+~lm ++|.l+..~+ +s ;~t+,~s+pW+|+p+ ++++l+ld le3m+1 + e +++l.h
d'+F',~+P P|+~+~p ++q+ jl +~lml+++++~+~l+l+itml+ ++~tl+ ;++i PlP+°tP +~+.+++lap+++l++m++lWq .~:~eq,++ t++~+++~+~:+.~+~l+,~l++p:++i+++d +it,+ m++a++~l|,llq+ y+ ++mk++~ +t++++~t~+.++xTl+m+mw.+++ p~++ +Ira+. /+++my+++m p~+~<+bl+d ++lull} s+ emom+!+~Jem+!++tpj o ++~el +~+ill +ill++ p+ ++>ml++iJ+~bti+alll .++:l~+~tlat++a++tla+l++++ +++t~ ++l;+m ir+,b++++ +~+ +oi¢+~mx~+ptm +u;sv++,+eqc+~+~q +;+dt+dS+tLL
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~01+ ~+++~I+~q~ ~ +'~+u+++++~+i~++q~+ ~!~+~l+~l~ ~+~'~ +~l~++~i~++~