Correspondence

Clinical Problem-Solving: The Pursuit of Certainty

N Engl J Med 1994; 330:644-645March 3, 1994

Article

To the Editor:

In their Clinical Problem-Solving article “A Rewarding Pursuit of Certainty” (Oct. 7 issue),1 Drs. Pauker and Kopelman discuss the treatment of a patient brought into the emergency room in status epilepticus. Evaluation with computed tomography (CT) and magnetic resonance imaging revealed a solitary ring-enhancing lesion in the left occipital lobe. The attending physicians then expended considerable effort searching for a presumed primary neoplasm before performing a brain biopsy, in the belief that “it would be nice to find a site other than the patient's brain to biopsy.” We found this diagnostic approach curious, because the treatment of choice for a solitary intracranial metastasis is complete surgical resection followed by radiation2,3. When modern anesthetic and neurosurgical techniques are used, the mortality rate associated with surgery for this patient should be just a fraction of a percentage point and the morbidity rate less than 1 percent.

In the past, it has been controversial which mode of therapy (radiation, surgery, or both) provided the best results with solitary intracranial metastasis. In the only prospective randomized trial3 to date, surgery followed by radiation as compared with radiation alone was found to provide the following statistically significant benefits: increased survival (median, 40 weeks, vs. 15 weeks for radiation alone), increased functional independence (median, 38 weeks, vs. 8 weeks), and less frequent recurrence at the site of the original metastasis (20 percent vs. 52 percent).

We apologize for digressing from the main point of an excellent presentation, but we believe that this is an important matter to raise in a teaching exercise. Unless there are mitigating circumstances that make a patient with a solitary brain metastasis an unsuitable candidate for surgery, we think one should not hesitate to perform a diagnostic and therapeutic resection in a timely manner.

Kenneth Mishark, M.D.
Michael Harrison, M.D.
David Grant U.S. Air Force Medical Center, Travis Air Force Base, CA 94535

3 References

1. 1

   Pauker SG, Kopelman RI. A rewarding pursuit of certainty. N Engl J Med 1993;329:1103-1107
   Full Text | Web of Science | Medline

2. 2

   Patchell RA, Cirrincione C, Thaler HT, Galicich JH, Kim JH, Posner JB. Single brain metastases: surgery plus radiation or radiation alone. Neurology 1986;36:447-453
   Web of Science | Medline

3. 3

   Patchell RA, Tibbs PA, Walsh JW, et al. A randomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med 1990;322:494-500
   Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Drs. Mishark and Harrison are correct: a solitary intracranial metastasis should be removed. Excision establishes the diagnosis and provides a better prognosis than does radiation therapy. Mishark and Harrison argue that the clinicians in this case should not even have been considering radiation therapy. But the diagnosis of cancer had not been established, and as it turned out, the actual diagnosis -- a brain abscess -- has a far better prognosis than metastatic cancer treated with either surgery or radiation therapy. Indeed, recent literature suggests that over the past three decades the decline in mortality among patients with a brain abscess has reflected a shift toward stereotaxic biopsy1-3. If that reasoning is correct, then some debate may remain about the optimal management of a single intracranial mass demonstrating ring enhancement on a contrast-enhanced CT scan. If it is an abscess, medical therapy may sometimes suffice; in other circumstances, an abscess may require a different surgical approach.

Stephen G. Pauker, M.D.
Richard I. Kopelman, M.D.
New England Medical Center, Boston, MA 02111

3 References

1. 1

   Ostertag CB, Mennel HD, Kiessling M. Stereotactic biospy of brain tumors. Surg Neurol 1980;14:275-283
   Web of Science | Medline

2. 2

   Apuzzo ML, Chandrasoma PT, Cohen D, Zee CS, Zelman V. Computed imaging stereotaxy: experience and perspective related to 500 procedures applied to brain masses. Neurosurgery 1987;20:930-937
   CrossRef | Web of Science | Medline

3. 3

   Marks PV, Hope JK, Thompson FJ, Cowan BR. CT stereotaxic brain biopsy: the Auckland experience. N Z Med J 1992;105:85-86
   Medline