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Long-Term Survival After Removal of Metastatic Malignant Melanoma of the Brain Report of Two Cases

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Long-Term Survival After Removal of Metastatic Malignant Melanoma of the Brain Report of Two Cases Long-Term Survival after Removal of Metastatic Malignant Melanoma of the Brain Report of Two Cases WILLIAM P. McCANN, M.D., BRYCE K. A. WEIR, M.D.,* AND ARTHUR R. ELVIDGE, M.D. Department of Neurology and Neurosurgery, McGill University and Montreal Neurological Institute, Montreal, Canada URVIVAL for more than a few years after lesion at the junction of the left occipital, removal of a metastatic intracranial parietal, and temporal lobes. S malignant melanoma is a rare occurrence. Operation. On November 9, 1951, a left Between 1928 and 1966, 32 patients have been parieto-occipital craniotomy was performed. treated at the Montreal Neurological Institute Brain pressure was high. A reddish tumor, 4 for metastatic melanoma of the brain, 21 of cm in diameter, was exposed at a depth of 3 them surgically. Follow-up data are complete cm posterior to the atrium of the lateral ven- on 27 patients (Table 1). Of those operated tricle. The tumor was removed totally; occipi- upon, all except two died within 2 years of tal and partial parietotemporal lobectomies craniotomy; one of these lived 14 years after were also necessary. He received postopera- the solitary brain metastasis had been excised tive radiation of 5,876 r delivered to the tumor while another is alive and well more than 10 bed over 2 months. years after operation. They apparently repre- Postoperative course. The patient was seen sent the longest postoperative survivals re- regularly in the Neurosurgery Clinic until corded in the English literature. 1963. There was improvement in the mental function and right-sided weakness. The papil- Case Reports ledema subsided, but the homonymous hemi- Case 1. In 1949, this 49-year-old man had anopsia and sensory impairment remained two pigmented nevi removed from his left unaltered. Although he was able to manage ear after they became enlarged. Histological well around his home, the patient was unable study revealed that the lesions were malignant to return to work. melanomata, incompletely excised. In 1957, he had several focal seizures on the He was admitted to the Montreal Neurolog- right side and deterioration in personality. ical Institute 2 years later because of progres- There was no conclusive evidence of tumor sive confusion and headache of 6 weeks' dura- recurrence. He was maintained on phenobar- tion and weakness of the right arm for 2 bital. weeks. Temper tantrums and poor judgment The mental changes were progressive. Sev- in business transactions had been evident for eral more seizures occurred in May, 1966. The 8 years and gradually failing vision for 2 years. patient's wife could no longer care for him at Examination. A large number of pigmented home, and he was admitted to a convalescent nevi were noted on the skin, and there was a hospital. He died on June 19, 1966, 48 hours well-healed scar of the left pinna. The per- after having a subarachnoid hemorrhage. tinent neurological findings were confusion, Pathological findings. The tumor removed euphoria, bilateral papilledema, and right- at operation was composed of sheets of sided homonymous hemianopsia, hemipare- densely packed cells (Fig. 1). These were ar- sis, cortical sensory loss, and Babinski sign. ranged in lobules which were contained by a Skull and chest x-rays were normal. Elec- thin stroma of connective tissue. Areas of troencephalogram suggested a lesion deep in necrosis were extensive. The tumor ceils were round or oval shaped with fairly distinct bor- the left temporal lobe. A ventriculogram out- lined a circumscribed expanding intracranial ders. Large, hyperchromatic nuclei with abundant chromatin masses were prominent, and cytoplasm was scanty. Pleomorphism Received for publication July 5, 1967. * Present address: Department of Neurosurgery, and mitoses were notable. In many places the University Hospital, Edmonton, Alberta. neoplastic cells lined up along blood vessels, 483 484 W. P. McCann, B. K. A. Weir and A. R. Elvidge TABLE 1 Metastatic melanoma to brain No. Longest No. Longest Nonsurgical Surgical Author Nonsurgical Survival Surgical Survival Cases (mos) Cases (yrs) Present series 11 11 16 14 7/12 10" Vieth 12 19 12 30 8 5/12" 6 1/4" Lang~ 22 5 5/6 5 11/12 Reyes 9 1 3 3/4* Stoier ~0 17 14 St6rtebecker~ 3 14 Moersch 8 4 6 mos Courville ~ 16 m 2 4 mos Gordon4 1 6 Wortis ,3 6 4 Globus3 1 5 * Still living when report was published. which were fairly numerous. Intercellular before admission, she had focal sensory sei- bridges and pigmented cells were not present. zures involving the left side of the face and Autopsy disclosed freshly clotted blood in arm, vomiting, and drowsiness. the fourth ventricle and upper cervical sub- Examination. The patient had sluggish reac- arachnoid space. The source of the bleeding tions, a drift of the left arm, a left Hoffman's was not discovered. There was no gross or sign, and impairment of position sensation, microscopic residual tumor in the left parieto- two-point discrimination, pinprick, and light occipital cavity. The main finding on general touch sensation in the left hand. There was no autopsy was bronchopneumonia. evidence of metastatic disease elsewhere in the body. Case 2. This 37-year-old woman was in Skull x-ray was normal. Ventriculography good health until June, 1953, when a small showed a space-occupying mass in the right skin lesion that had been present on her right cerebrum. The ventricular cerebrospinal fluid arm began to discharge. The lesion was ex- protein was 28 mg %. cised locally, and a histological diagnosis First operation. On June 28, 1956, a right of malignant melanoma was made. No x-ray parietal craniotomy was performed. Brain therapy was given. A right axillary dissection pressure was high. The centroparietal convo- was carried out 1 year later, but no metastases lutions were widened. The tumor was dis- were found. covered at a depth of 1 cm in the posterior The patient remained well until May, 1956, parietal region near the midline. It had a dark when she developed progressive bifrontal grey color and was somewhat translucent. headaches, followed over the next several The mass was separated from the brain fairly weeks by a gradual loss of sensation and sub- easily by blunt dissection and was delivered by jective weakness of the left arm. In the week finger. .
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