The management of brain metastasis in nonseminomatous germ cell tumours

Objective To review our experience of patients with brain metastases from n onseminomatous germ cell tumours (NSGCTs) and to indicate important clinica l observations. Patients and methods Between 1990 and 1996, 167 patients with metastatic NS GCT were treated in our department; II had brain metastases (eight with sol itary metastases and three with multiple lesions, mean age 27 years, range 18-41). These patients were treated initially with either; cisplatin, bleom ycin, etoposide and/or cisplatin, vincristin, methotrexate, bleomycin, acti nomycin-D, cyclophosphamide, etoposide and intrathecal methotrexate chemoth erapy protocols. Six patients received chemotherapy alone, one had chemothe rapy plus radiotherapy and four had all three treatments. Patients with bra in metastases were classified according to mode of presentation, and their treatments and outcomes analysed. Results Ten patients presented with symptoms related to intracranial lesion s, e.g. intractable headache, seizures, severe vomiting, hallucinations and hemiparesis. All patients with brain metastasis had bulky thoracic disease . The incidence of clinical brain metastases in patients with advanced thor acic disease was 32% (11/34). Four patients with brain metastases at presen tation were alive after 3, 12, 34 and 47 months. The only patient with isol ated brain relapse died within 7 months, despite combined treatment, Tno of the five patients who developed brain metastases during the course of the disease are alive with no evidence of disease at 3 and 6 months after salva ge chemotherapy. Conclusion Patients with single brain metastasis seem to have a better prog nosis in the present than in other reported series. Chemotherapy was used i nitially, followed by surgery and radiotherapy in those who did not achieve complete remission with chemotherapy. Patients with progressive disease an d multiple brain metastasis do not seem to benefit from initial surgical re section, Importantly, a significant proportion (32%) of patients with bulky lung metastases had or subsequently developed brain metastases. Thus it is suggested that routine cranial imaging should be performed in patients wit h bulky thoracic disease.