脳移転を反復したalveolar soft-part sarcomaの1症例—転移性脳腫瘍に対する手術適応

A CASE of ALVEOLAR SOFT-PART SARCOMA WITH RECURRENT CEREBRAL METASTASIS:OPERATIVE MANAGEMENT FOR CEREBRAL METASTASIS

　抄録　Alveolar soft-part sarcomaは稀な軟部腫瘍であるが，脳転移をきたすことが珍しくない。今回我我は10年間に8回の脳転移摘出術を施行し，その間ほぼ社会人として有意義な生活を送った女性患者を経験した。最近では転移性脳腫瘍に対し，積極的に摘出術が施行されているが，我々は転移性脳腫瘍が単に技術的な摘出可否のみによって手術適応を決定するのではなく，現病巣による生命予後が約6か月以上あり，しかも摘出後患者の生活に著しい影響を与えない場合，ならびに現病巣が未確認の場合を適応と考えており，本症例もこの原則に従って治療を施行した。本症例のように悪性であるが非常に発育の遅い腫瘍は転移性脳腫瘍の手術適応を考える上で，一般的な癌転移とは少し異なった観点での検討が必要であることを論じた。

A female patient noticed a painless swelling at the right thigh at the age of 12. Two years later, she had total removal for the tumor and irradiation, The diagnosis of the tumor was alveolar soft-part sarcoma. At the age of 16 she had left pneumonec-tomy for its metastasis. The next year the me-tastatic tumor is detected in the right lung. At 21 she was admitted to our service with a diagno-sis of cerebral metastasis. Her chief complaints were headache, nausea and visual disturbance. Neurological examination revealed advanced choked disc and left homonimous hemianopsia. CT scan revealed a large vascular tumor in the right occipital lobe and chest film showed multiple metastatic shadows in right lung. A large bloody tumor was removed totally through right occipital craniotomy. She was discharged with a marked improvement of neurological symptom. Since thenshe had had 8 times of surgical removal for 10 cerebral metastatic tumors. Several chemotherapy was attempted for three times. At first adriamycin was administered after the first removal of cerebral metastasis. Methyl-CCNU and Picibanil was ad-ministered after the second removal. Soon after the chemotherapy, metastatic tumor recurred. Cis-platin was administered for the ninth metastasis. None of these chemotherapy had seemed to be benefit in the management. At 27 she had removal of metastatic tumor on chest wall. She died of respiratory embarrassment in thorax at 30. At autopsy she had metastatic tumors in right frontal lobe, right lung, mediastinum, heart, chest wall, and intestine. During her illness, she graduated from high school and college, and got a good job as a secretary.

Indication or choice of surgical treatment for various metastatic cerebral tumors is still contro-versial to data. Neurosurgeon, however, should have own logical standard for decision of this in-dication considering social, religious, philosophi-cal or even economical respects, as well as tech-nical situation. This is brief summary of our policy for metastatic cerebral tumors ; surgical re-moval is recommended for cases with longer than 6 months of life expectancy due to primary lesion and low possibility of additional neurological de-ficits threatening significant life. Operation is re-commended if the diagnosis of the intracranial lesion or localization of primary lesion is uncer-tain.

For this patient, we had decided the removal of cerebral metastatic tumors according to previous mentioned policy. Difference between recurrent metastatic tumor of such characteristic slow grow-ing malignant tumor and that of other carcinomas was emphasized in surgical points of view.