Frameless Fractionated Gamma Knife Radiosurgery with ICON™ for Large Metastatic Brain Tumors

BACKGROUND: Recently, a new generation of gamma knife radiosurgery (GKRS) equipped with a frameless immobilization system has encouraged the use of fractionated GKRS as an increasingly favorable treatment option. We investigated the preliminary outcome of efficacy and toxicity associated with frameless fractionated gamma knife radiosurgery (FF GKRS) for the treatment of large metastatic brain tumors. METHODS: Fifteen patients with 17 lesions were treated using FF GKRS and included in this study, because of the large tumor size of more than 10 cm3. FF GKRS was performed based on a thermoplastic mask system for 3 to 5 consecutive days. RESULTS: The mean duration of clinical follow-up was 12 months (range, 4–24), and the local control rate was 100%. Tumor volume decreased in 13 lesions (76.5%), and remained stable in 4 lesions (23.5%). One patient was classified as new lesion development because of the occurrence of leptomeningeal seeding regardless of the tumor volume change. Compared with the initial volume at the time of FF GKRS, tumor volume change at the last follow-up was 62.32% ± 29.80%. Cumulative survival rate at 12 months was 93.3% ± 6.4%. One patient died during the follow-up period because of the progression of the primary disease. No patient showed radiation necrosis on the follow-up images. CONCLUSION: Daily FF GKRS by gamma knife ICON™ revealed satisfactory tumor control rate and low morbidity, despite the short follow-up period. Further prospective studies and a longer follow-up of a large cohort of patients diagnosed with brain metastases are required to elucidate the effect of FF GKRS in brain metastases.

A Case of Brain Edema Caused by Radiation Necrosis After Stereotactic Radiosurgery Treated with Saireito / 日本東洋医学雑誌

A 60-year-old female patient was treated with gamma knife on the left frontal lobe metastatic brain tumor. After 3 months, the tumor and peri-focal edema turned worse due to radiation necrosis. Despite increasing doses of steroid administration, the deterioration lasted for 6 months. The symptoms and brain edema did not improve for over a year, but we decided to observe the patient without bevacizumab. We performed Methionine-PET to diagnose radiation necrosis of the brain, and confirmed absence of hot spots. The steroid therapy continued and added saireito 9 g/day, because we thought brain edema was concerned with fluid retention. After 9 months, head MRI showed improvements of the brain edema. Saireito may help improve brain edema due to radiation necrosis.

Differentiation of glioblastomas and solitary metastatic brain tumors using texture analysis of conventional MRI / 中华放射学杂志

Objective To investigate the diagnostic value of the texture analysis derived from conventional MR imaging in differentiating glioblastomas from solitary brain metastases. Methods Thirty-four patients with pathological diagnoses of glioblastomas and 34 patients with pathological diagnoses of solitary brain metastases were enrolled in our study. All patients underwent conventional MR imaging including axial T1WI, T2WI, fluid attenuated inversion recovery (FLAIR) and contrast-enhanced T1WI before surgery. Texture features were calculated from manually drawn ROIs by using MaZda software. The feature selection methods included mutual information (MI), Fishers coefficient, classification error probability combined with average correlation coefficients (POE+ACC) and the combination of the above three methods. These methods were used to identify the most significant texture features in discriminating glioblastomas from metastases. Then the statistical methods including raw data analysis (RDA), principal component analysis (PCA), linear discriminant analysis (LDA) and nonlinear discriminant analysis (NDA) were used to distinguish glioblastomas from metastases. The results were shown by misclassification rate. Meanwhile, two senior radiologists (who had 5 and 9 years of experience in neuroimaging diagnosis, respectively) analysed the data of the 68 patients. Chi-square test was used to compare the differences in the results between the radiologists' analysis and the texture analysis. Results In the four kinds of sequences, the texture features for differentiating glioblastomas from solitary brain metastases were mainly from T2WI which had the lowest misclassification rate, 8.82% (6/68). The misclassification rates of the feature selection methods were similar in MI, Fisher's coefficient and POE + ACC (10.29%-27.94% for MI;11.76%-44.12% for Fisher's coefficientand 8.82%-38.24% for POE+ACC). However, the misclassification rate of the combination of the three methods (8.82%-33.83% for FPM) was lower than that of any other kind of method. In the statistical methods, NDA (8.82%-11.76% ) had lower misclassification rate than RDA (26.47%-39.71% ), PCA (27.94%-39.71%) and LDA (13.24%-44.12%). Misclassification rate of the radiologists' analysis 14.71%(10/68) was higher than that of the texture analysis, but there was no statistically difference between them (χ2= 10.993, P=0.287). Conclusion Texture analysis of conventional MR imaging can provide reliably objective basis for differentiating glioblastoma from solitary brain metastasis.

Discussion about 2 cases of intractable headache from brain tumor in which opioids were effective and a hypothesis regarding the underlying mechanism

Headaches caused by metastatic brain tumors result from dural tension and traction of the sites of nociceptive nerves that originates from displacement of cerebral vessels and intracranial hypertension caused by the tumor. Causes of such headaches also include meningeal irritation resulting from intrathecal dissemination of tumor and carcinomatous meningitis.Treatment of headaches resulting from intracranial hypertension involves alleviation of cerebral edema and reduction of intracranial pressure using hyperosmolar therapy and steroid administration, but treatment is often complicated by a lack of pressure reduction. We encountered 2 cases of headaches with intracranial hypertension that did not improve following hyperosmolar therapy and steroid administration, but resolved with increased opioid dose.In cases where intracranial pressure does not decrease, or for headaches attributed to direct stimulus of intracranial nociceptive nerves rather than intracranial hypertension, attempts to treat the patient with initiation or increased dosage of opioids may prove effective from a clinical standpoint.

Comparative Analysis of Efficacy and Safety of Multisession Radiosurgery to Single Dose Radiosurgery for Metastatic Brain Tumors

BACKGROUND: The purpose of this study is to compare the efficacy and safety of multisession radiosurgery to those of single dose radiosurgery for metastatic brain tumors. METHODS: Between February 2008 and February 2012, 90 patients with 196 metastatic brain tumors were treated with cyberknife radiosurgery, and we reviewed these patients retrospectively. Among them, 57 patients underwent single dose radiosurgery, and 33 patients multisession radiosurgery. Tumors involving the eloquent area and large tumors (>5 cc) were treated with multisession radiosurgery. The median tumor volume and the median treatment dose of single dose radiosurgery were 2.05+/-0.72 cc and 19.76+/-1.54 Gy respectively, and in the case of multisession radiosurgery, 5.30+/-1.70 cc and 29.6+/-1.70 Gy respectively. The frequency of multisession dose was 3 to 5 times, on average 3.55 times, and 8.91 Gy were given per 1 session on average. RESULTS: The overall survival (OS) of multisession radiosurgery was 16.0 months, whereas that of single dose radiosurgery was 11.5 months. The radiologic tumor response rates were 90% in single dose radiosurgery and 95.4% in multisession radiosurgery, respectively. Over 6-month and 1-year periods, the OS rates of single dose radiosurgery were 71.4% and 44.9%, whereas those of multisession radiosurgery were 69.1% and 58.3%, respectively (p=0.83). Toxicities were seen in 18.1% in the single dose radiosurgery group versus 4% in the multisession radiosurgery group. The difference was significant (p<0.05). CONCLUSION: In this study, the multisession radiosurgery group, despite the location and size constraints, did not differ from the single dose radiosurgery group when comparing the survival and recurrence rates, but complications and toxicity were lower. Thus, multisession radiosurgery is thought to be beneficial for treatment of large tumors and tumors located in the eloquent area.

Small Cell Lung Cancer at Subcarina Presenting as a Metastatic Brain Tumor

A 59-year-old man was rushed to the emergency room. The patient complained of headache with impaired memory function. Brain MRI showed a necrotic tumor in Lt cerebral hemisphere, with severe peritumoral edema (Fig. 1). Pathologic examination of the brain lesion confirmed that the tumor was a small cell lung cancer (SCLC). Chest computed tomography revealed a large soft tissue mass with central necrosis at subcarinal area in spite of an initial normal chest X-ray (Fig. 2). Bronchoscopic biopsy of the polypoid mass at subcarina revealed that the mass was a SCLC (Fig. 3). This is the case of SCLC only with an extrapulmonary symptoms despite of a normal chest X-ray. When metastatic brain tumor was found, appropriate chest evaluation should be performed even though chest X-ray was normal because brain is a common site of invasion of lung cancer.

A Case of Radiation Retinopathy of Left Eye After Radiation Therapy of Right Brain Metastasis

A 37-year-old female, who had received modified radical mastectomy for cancer of her right breast, presented with decreased visual acuity in the left eye after radiation therapy for the management of the metastasis to her right brain 14 months ago. After ocular examination, we diagnosed her as radiation retinopathy. At the time of the first visit, the corrected best visual acuity was 0.4 in the left eye, and fundus examination revealed cotton wool spots and cystoid macular edema (CME). The findings in the right eye were normal except for cotton wool spots in the superior major arch. Fluorescein angiography (FA) showed marked telangiectasia and microaneurysms in her left eye but tiny microaneurysms in her right eye. Subsequent optical coherent tomography (OCT) showed CME. We injected intravitreal triamcinolone acetonide (TA). Two weeks after treatment, the visual acuity was improved to 0.6 and the retinal thickness was decreased. Three months later, the visual acuity in the left eye was dropped to 0.3 due to the recurrence of CME, so we injected intravitreal TA again. Five months later, visual acuity was improved to 0.5 and OCT revealed the improvement of CME. The incidence of radiation retinopathy is higher in the side nearer to radiation, but careful radiation blocking is also required on the opposite side of irradiation site considering the possibility of radiation retinopathy and careful observation is required on both sides of the eyes when performing fundus examination.

LINAC Radiosurgery for Metastatic Brain Tumors

OBJECTIVE: The authors take a group of patient who have undergone radiosurgery for the treatment of metastatic brain tumor, and conduct a retrospective analysis on the therapeutic response and prognotic factors which influenced the outcome. METHODS: The cases of metastatic brain tumor managed with radiosurgery at our hospital between January of 1996 and December of 2000 were 26. Second radiosurgery was performed for new metastasis in two patients. RESULTS: Average age of patients was 59.3 years. A single lesion was found in 17 cases while multiple lesions were found in 11 cases. Median survival period of the pateints who have undergone radiosurgery was 53 weeks, and survival rate at 6 months, 12 months, and 24 months was 84.6%, 53.9%, and 19.6% respectively. Overall tumor-control-rate was 92.9%. There was one case of radiation necrosis as a complication. Extracranial metastasis, controlled primary cancer and above 70 of Karnofsky performance scale score were statistically significant prognostic factors for survival. CONCLUSION: Radiosurgery is safe and effective in the treatment of metastatic brain tumor. And the control of primary malignant tumor, the presence of extracranial metastasis and above 70 of KPS have seen shown to influence the therapeutic response and prognosis.

Fractionated Stereotactic Radiotherapy for Metastatic Brain Tumor in Non-Small Cell Lung Cancer

PURPOSE: To evaluate the results of treatment with fractionated stereotactic radiotherapy for metastatic brain tumors in non-small cell lung cancer. MATERIALS AND METHODS: Between August 1997 and August 2001, 17 patients, with metastatic brain tumors in non-small cell lung cancer (26 lesions), completed frameless fractionated stereotactic radiotherapy. All patients received a 30~36 Gy/10~20 fx external beam irradiation to the whole brain. Twelve received fractionated stereotactic radiotherapy for a single lesion, 3 for 2 lesions and 1 each for 3 and 5 lesions. The median tumor volume was 1.7 cc (0.3~55.2 cc). The fractionation schedule for the fractionated stereotactic radiotherapy was 21 Gy/3 fx in 8 lesions, 25 Gy/5 fx in 7, 18 Gy/1 fx in 6, 30 Gy/5 fx in 4 and 15 Gy/5 fx in 1. Multiple-arc, and 3D conformal, fractionated stereotactic radiotherapy, were delivered to 24 and 2 lesions, respectively. Follow-up was possible in all patients. RESULTS: Nine out of 13 patients with follow-up radiological evaluations achieved a complete response (CR). The overall median survival, and 1 and 2 year survival rates were 20 months, and 64 and 28%, respectively. The median survival, and the 1 and 2 year survival rate of CR group were 20 months, and 73 and 22%, respectively. No patient has experienced any acute side reactions or late complications from the fractionated stereotactic radiotherapy. CONCLUSION: Although the number of patients treated with fractionated stereotactic radiotherapy was small, and follow-up period short, this study suggests that external beam irradiation to the whole brain, with 30 Gy/10 fx followed by fractionated stereotactic radiotherapy, could be a good treatment option for patients with metastatic brain tumors in non-small cell lung cancer.

Vascular Endothelial Growth Factor-C Expression in Primary and Metastatic Brain Tumor

OBJECTIVE: Vascular endothelial growth factor(VEGF)-C is involved in lymphangiogenesis and spreading of cancer cells via lymphatic vessels. The aim of the present study is to investigate the relationship between the absence of cerebral lymphatic vessels and low metastatic rate of brain tumors. METHODS: Immunohistochemical stains were performed for VEGF-C and VEGF in surgically resected specimens from 57 patients with primary(38 cases, low grade : 10 cases, high grade : 28 cases) and metastatic(19 cases) brain tumor. RESULTS: The expression of VEGF-C was higher in metastatic carcinoma(68%) than in high-grade primary tumor(29%). There was no difference for VEGF expression between high grade brain tumor (71%) and metastatic carcinoma(58%). CONCLUSION: Low VEGF-C expression of primary brain tumors may play a role in low metastatic rate of brain tumors.

Initial Experience of Fractionated Stereotactic Radiotherapy for Metastatic Brain Tumors / 대한암학회지

PURPOSE: This study aimed to evaluate the preliminary treatment results of fractionated stereotactic radiotherapy (FSRT) for metastatic brain tumors. MATERIALS AND METHODS: Between August 1997 and December 1998, frameless FSRT was performed in 11 patients with metastatic brain tumor (1S lesions). Primary sites were lung in 7 patients, breast in 2, stomach in 1, and malignant melanoma in 1, All patients received 30-36 Gy/10-20 fx external beam irradiation to whole brain. Eight patients received FSRT for 1 lesion, one for 2 lesions, and two for 4 lesions. Fractionation schedule was 25 Gy/5 fx in 11 lesions, 18 Gy(1 fx in 3, 30 Gy/5 fx in 2, 15 Gy/5 fx in 1. Mean tumor volume was 7.0 cc (0.39~55.23 cc). Multiple-arc FSRT was delivered to 16 lesions and conformal FSRT through irregular ports shaped to tumor profile to 2 lesions. RESULTS: No patient experienced any acute side reaction from FSRT. Follow-up radiologic evaluation was available in 9 patients. Six of nine patients achieved the complete response, but two showed the partial response and one showed no response on follow-up radiologic studies. Among six patients with complete response, 5 patients survived from 5 to 15 months and showed no evidence of metastatic brain d#isease clinically and/or radiologically at last follow-up. Among two patients who did not have radiologic evaluation, one showed clinically complete response until death and the other died just after FSRT caused by intercurrent disease. One patient with no response radiologically survived 7 months and showed nearly complete disappearance of clinical symptom with stable status radiologically, CONCLUSION: Initial experience in this study suggests that the external beam irradiation to whole brain with 30 Gy/10 fx followed by FSRT with 20~30 Gy/5~6 fx could be the good treatment option to the patients with metastatic brain tumor. This study suggests that the fractionation schedule for FSRT should be determined in consideration of performance status, number of metastasis, tumor volume, location, presence of extracranial disease, and age.

Gamma Knife Radiosurgery for Single & Multiple brain Metastasis

Metastatic brain tumors have been considered to be a good candidate for surgery because they are usually noninfiltrative to adjacent normal brain tissue and spherical in shape. These conditions meet the necessities for radiosurgery. Between May 1990 and Dec. 1994, 57 patients with metastatic tumors were treated radiosurgically using Leksell gamma unit at Asan Medical Center. Among 57 patients with metastatic brain tumors, 33 patients had 76 tumors that were followed-up clinically and radiographically. Sixty-two tumors disappeared or decreased in size and 8 tumors remained stable until 3 to 6 months after radiosurgery on CT or MRI scans. Local recurrence rate was 8% and tumor control rate was 92%. Median survival time was 15 months. New metastases were noted in 11 patients during follow-up periods. Gamma Knife radiosurgery appears to be the best therapeutic method for single and multiple brain metastases. The short hospitalization time and the benignity of the procedure are of special importance for patients with a short life expectancy.

A case of Metastatic Brain Tumor Associated with Typical Meningeal "Tail Sign"

Many authors have been concerned with the diagnosis and management of meningioma which is widely-known to have a high incidence and that its total removal can result in a good prognosis. Magnetic resonance imaging (MRI) with gadolinium enhancement technique has enabled an easier diagnosis of meningioma. Among the radiographic signs of meningioma, the so-called meningeal "tail sign" is thought to be a highly specific sign for meningiomas. However, some cases of dural based tumors(lympoma, schwannoma, sarcoidosis) with the meningeal tail sign have recently been reported. Also, some authors have suggested that the meningeal tail sign may also been taken to indicate the extent of dural involvement of meningiomas. We report our experience of a case of metastatic brain tumor with the typical meningeal tail sign along with a review of the literatures. The findings of this case suggest that the meningeal tail sign is not a specific sign reserved only for meningioma.

Clinical Report of 46 Intracranial Tumors with LINAC Based Stereotactic Radiosurgery / 대한치료방사선과학회지

Between July 1988 and December 1992, we treated 45 patients who had deep seated inoperable or residual and/or recurrent intracranial tumors using LINAC based stereotactic radiosurgery at the Department of Therapeutic Radiology, Kangnam St. Mary's Hospital, Catholic University Medical College. Treated intracranial tumors included pituitary tumors(n=15), acoustic neurinomas(n=8), meningiomas(n=7), gliomas(n=6), craniopharyngiomas(n=4), pinealomas(n=3), hemangioblastomas(n=2), and solitary metastatic tumor from lung cancer (n=1). The dimension of treatment field varied from 0.23 to 42.88 cm3(mean ; 7.26 cm3). The maximum tumor doses ranging from 5 to 35.5 Gy (mean; 29.9 Gy) were given, and depended on patients' age, target volume, location of lesion and previous history of irradiation. There were 22 male and 23 female patients. The age was varied from 5 to 74 years of age(a median age; 43 years). The mean duration of follow-up was 35 months (2~55 months). To date, 18(35.1%) of 46 intracranial tumors treated with SRS showed absent or decrease of the tumor by serial follow-up CT and/or MRI and 16(34.8%) were stationary, e.g. growth arrest. From the view point of the clinical aspects, 34(73.9%) of 46 tumors were considered improved status, that is, alive with no evidence of active tumor and 8(17.4%) of them were stable, alive with disease but no deterioration as compared with before SRS. Although there showed slight increase of the tumor in size according to follow-up imagings of 4 cases(pituitary tumor 1, acoustic neurinomas 2, pinealoma 1), they still represented clinically stable status. Clinically, two(4.4%) patients who were anaplastic astrocytoma(n=1) and metastatic brain tumor(n=1) were worsened following SRS treatment. So far, no serious complications were found after treatment. The minor degree headache which could be relieved by steroid or analgesics and transient focal hair loss were observed in a few cases. There should be meticulous long term follow-up in all cases.

Prognosis of the Parenchymal Brain Metastasis According to Primary-to-Metastatic Interval

The authors analyzed and compared three prognostic factors of the intraparenchymal metastatic brain tumors, regardless of therapeutic modalities, to evaluate the value of time-interval between diagnosis of primary cancer and brain metastasis as a prognostic factor. Our of the 109 patients of metastatic brain tumor admitted to Kosin Medical College from 1984 to 1991, 93 patients were included in this retrospective study. The survival time of these patients was statistically evaluated according to each prognostic factor. The results were as follows. Patients with mild or no neurological deficits and patients with moderate neurological deficits showed longer survival than the patients with severe neurological deficits(P<0.001). The presence of systemic metastasis at the time of diagnosis also significantly shortened overall survival(P<0.0095). Primary-to-metastatic interval did not significantly affect overall survival(P<0.6164), but the patients with brain metastasis detected within 1 year after diagnosis of the primary cancer had a longer median survival than those detected after 1 year(P<0.001). We conclude that the primary-to-metastatic interval is not valuable as a prognostic factor for intraparenchymal metastatic brain tumor, and further prospective study tailored to each specific condition will be needed for more accurate evaluation of prognostic factors.

A Clinical Analysis of Metastatic Brain Tumors

We have studied 1927 cases of primary tumor patients, who were admitted, managed and registered at Cancer Center of Maryknoll Hospital from Nov. 1985 to Jun. 1988. Of these, 50 cases were metastasized to central nervous systems, and the cases of brain metastases were 31 cases. This report presents an analysis of 31 cases of metastatic brain tumors. The results are as followings: 1) The sexes were represented with 20 males and 11 females. In 20 cases(65%), the metastases occurred between the 6th decade and 7th decade. 2) The most frequent anatomical site of brain metastases was brain parenchyme(67.7%). 3) The most frequent site of primary malignancy was lung(45.2%), and the next order was choriocarcinoma of the uterus. 4) The clinical symptoms and signs of metastatic brain tumors were headache(87%), nausea, vomiting(35.5%) orderly. 5) In C-T scan findings, the metastatic brain tumors presented hyperdense area at 50% of cases before contrast enhancement, and were enhanced nearly almost of cases. 6) In cases which could be treated surgical procedure, radiation and chemotherapy seemed to improve the prognosis.

A Retrospective Analysis of Treatment and Prognosis in Brain Metastases

A retrospective analysis of brain metastasis with respect to the pathology, hydrocephalus, cause of death, survival time and therapeutic modality was carried out in 47 cases. The duration of survival after CNS metastasis far less depends on the primary tumor than the latent interval between the onset of first symptom from primary tumor and CNS metastasis dose. And death was attributable to the CNS metastases in at least 5.3% of these cases. Surgery and radiotherapy but chemotherapy were included in this study. Radiotherapy had significant effects on prolongation of survival. The surgery plus postoperative whole brain radiotherapy had the longest survivals than the other treatment modalities. The authors recommend guidelines for surgical resection, usually followed by radiotherapy:in cases which have good general condition enough to tolerate general anesthesia without any acute general morbidness, (1) single surgically accessible brain metastasis, (2) an incapacitating or large metastasis even when the tumor is not solitary, (3) uncertain primary cancer, (4) posterior fossa, especially cerebellar hemispheric metastasis. It seems that the presence of metastasis else where in the body should not exclude the case as a surgical candidate.

A Retrospective Analysis of Treatment and Prognosis in Brain Metastases

A retrospective analysis of brain metastasis with respect to the pathology, hydrocephalus, cause of death, survival time and therapeutic modality was carried out in 47 cases. The duration of survival after CNS metastasis far less depends on the primary tumor than the latent interval between the onset of first symptom from primary tumor and CNS metastasis dose. And death was attributable to the CNS metastases in at least 5.3% of these cases. Surgery and radiotherapy but chemotherapy were included in this study. Radiotherapy had significant effects on prolongation of survival. The surgery plus postoperative whole brain radiotherapy had the longest survivals than the other treatment modalities. The authors recommend guidelines for surgical resection, usually followed by radiotherapy:in cases which have good general condition enough to tolerate general anesthesia without any acute general morbidness, (1) single surgically accessible brain metastasis, (2) an incapacitating or large metastasis even when the tumor is not solitary, (3) uncertain primary cancer, (4) posterior fossa, especially cerebellar hemispheric metastasis. It seems that the presence of metastasis else where in the body should not exclude the case as a surgical candidate.

Clinical Analysis of Metastatic Brain Tumors

The author analyzed 153 cases of metastatic brain tumors, including diagnostic and therapeutic aspects, who had been admitted to Yonsei University College of Medicine and Jeonju Presbyterian Medical Center from January, 1976 to August, 1983. Results obtained are as follows: 1) Metastatic brain tumors constituted 16.5% of all brain tumors. 2) The majority of patients was in the age range of 41 to 60 years. 3) The most common primary tumor with brain metastasis was lung carcinoma(45.1%). 4) Headache was the single most common presenting symptom of cerebral metastasis. 5) The most frequent intracranial locations of metastatic brain tumors were parietal and frontal lobe. 6) The computed tomographic scan has become the single most valuable and accurate diagnostic tool for investigation of metastatic brain tumor. It was also important study in evaluating the effect of treatment. Multiplicity of lesions was an important diagnostic feature. Also densely enhancing, and homogeneous cortical mass surrounded by edema with finger-like projections was a common characteristic feature. 7) Combined therapy-surgical excision followed by whole brain radiotherapy and/or chemotherapy-had been shown to result in better prognosis than either modality alone. The 6 months survival rate of combined therapy was 66.7% and it was more efficient in prolonging the patient's quality of life than the other methods currently available. In some instances, admittedly rare, long-term survival could be achieved. When the metastatic mass was producing wevere neurological disability because of its location, and the prognosis was otherwise reasonable, significant palliation and improvement in the patient's neurological status could be secured by surgical removal.