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Ann Thorac Surg 1996;61:551
© 1996 The Society of Thoracic Surgeons
Department of Thoracic Surgery, Frenchay Hospital, Bristol BS16 1LE, England
Yokoi and associates contend that the outcome of treatment of brain metastases from bronchogenic carcinoma has in the past been poor because of the delay in detection until symptoms have supervened. In their attempt to explore if routine postoperative scanning at frequent intervals would prove effective in early detection of such metastases they have embarked on computed tomographic scanning as the technique of choice. Today, however, they would probably choose contrast-enhanced magnetic resonance imaging of the brain in preference because of the latter's proven higher sensitivity and total lack of radiation dosage. The availability of the technique would undoubtedly dictate its applicability. If one looks at using any imaging technique for routine repetitive scanning, one has to consider the likely positive yield as opposed to the cost to justify the cost logistics.
It is well established that the cell type of the primary tumor to some extent determines the likelihood of metastases after curative operation, glandular and anaplastic carcinomas being more likely to metastasize than well-differentiated squamous carcinomas. Tumors in the upper lobes are more likely to metastasize to the brain than those in the lower lobes. Furthermore, tumors in stage II and IIIa are more likely to have thrown off microscopic metastases than tumors in stage I.
If one looks at the patients in the series analyzed by Yokoi and associates, glandular and anaplastic carcinomas accounted for 10 of the 11 such cases of brain metastasis detected in a total of 76 patients with this cell type whereas there was only 1 well-differentiated squamous carcinoma with brain metastases in a total of 52 resected patients. Of all 11 patients in whom brain metastases developed, 10 had their primary tumors resected from the ``upper lobes'' if one considers the middle lobe as being developmentally and segmentally part of the upper lobe.
Finally, 9 of 11 patients with metastases were in stage IIIA at the time of resection and the other 2 had adenocarcinomas in stage I. Thus the evidence from this article shows that if one is to carry out repetitive postoperative scanning of patients who have undergone operation for non–small cell carcinoma of the bronchus, it is best done in the first 6 months at 2-month intervals in all patients who had ``glandular or anaplastic'' carcinomas of any stage in all ``upper lobe'' tumors. However, for squamous carcinomas the need for such screening can be limited to those who had their primary tumor resected in stage IIIA. Had Yokoi and associates provided a breakdown of the numbers of each stage for individual cell type in the whole series studied, one may be able to refine the cost-effective applicability even further.
Yokoi and associates are to be congratulated on undertaking the study and demonstrating that with meticulous search for asymptomatic brain metastases, prolongation of a good quality of life can be achieved even when the primary tumor was resected at a time when microscopic metastases may have occurred.
Related Article
Ann. Thorac. Surg. 1996 61: 546-550.
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