A never-smoking woman aged 85 years was transferred to our hospital for further examination of a brain tumor. She had a history of right lower lobectomy with tuberculosis at age 27 years, a left lower lobe reduction surgery for non-small cell carcinoma at age 76, and bronchial asthma at age 80, with no recurrence of lung cancer and good control of bronchial asthma. She became aware of a headache in X-3 month and visited a nearby hospital with dysarthria in X-2 month, at which time a cerebral infarction was diagnosed by CT and an antiplatelet drug was started. However, right hemiplegia newly occurred, and the dysarthria worsened in X-1 month. She was transferred to our neurosurgery department after an additional brain MRI scan revealed a brain tumor in the left parietal lobe.
On admission, she had motor aphasia and right paresis without sensory disturbance. Brain MRI showed a single tumor with extensive edema around 19 x 25 x 21 mm in size in the left parietal lobe, and chest CT showed a 38-mm tumor adjacent to the sutures of the previous lobectomy in the lower lobe of the left lung (Fig. 1, Fig. 2A). We suspected intrapulmonary recurrence and metastatic brain tumor based on imaging findings started glycerol at 600 mg/day and performed CyberKnife therapy on day 12. After adding dexamethasone 6.6 mg/day, her dysarthria and right paresis improved, and glycerol and corticosteroid administration was terminated on day 23. However, hemiplegia and aphasia gradually worsened a few days later, and repeat brain MRI showed further exacerbation of edema (Fig. 1-B). On day 27, glycerol and corticosteroid administration were resumed preoperatively, and LEV administration was also begun. Left parietal tumor resection was performed on day 31. Postoperative pathology revealed that the tumor was positive for cytokeratin AE1/AE3, negative for thyroid transcription factor 1, and positive for p40, suggesting brain metastasis of lung squamous cell carcinoma (Fig. 2-D-G). We diagnosed the recurrence of non-small cell lung carcinoma that we determined to be stage IV A (cT2aN0M1b) and performance status 3. The brain tumor specimen removed was positive for epidermal growth factor receptor (EGFR) mutations (L858R). The tumor proportion score of anti-programmed cell death ligand 1 was 70%. Postoperatively, rehabilitation was resumed, corticosteroid therapy ended on day 54 due to improvement of the edema on brain MRI (Fig. 1-C), and only LEV was continued to prevent seizures.