the median survival rate reported for surgically treated patients with brain metastases from melanoma ranges from 5 to 22 months .
the most significant factor influencing the survival of patients with brain metastases is the number of their cerebral metastases .
surgical treatment of multiple brain metastases is only considered a palliative solution for improving the quality of life .
however , recently the performance of multiple resections of brain metastases from melanoma has led to a reconsideration of the surgery s benefits .
we report one case of multiple brain metastases from malignant melanoma with two large lesions located in the right frontal and left parietal lobes .
this is a case report of simultaneous one - stage resections of distant lesions with two approaches for multiple metastatic malignant melanoma lesions .
a 41-year - old woman had a mole in her right ear that grew noticeably , and swelling was detected in her right neck lymph nodes .
aspiration biopsy cytology of the neck lymph node was performed , and malignant melanoma was diagnosed .
she underwent an operative resection of the ear lesion , right neck lymph nodes and parotid gland with subsequent chemotherapy and radiotherapy .
her level of consciousness had deteriorated , and she was transferred to our hospital 6 months after being diagnosed with malignant melanoma . on admission ,
her glasgow coma scale score was 11 ( e2v3m6 ) , and she had a right hemiparesis .
additionally , symptoms of gerstmann syndrome such as finger agnosias , right - left disorientation , acalculia and agraphia were noted .
computed tomography showed two large lesions in the right frontal lobe and left parietal lobe surrounded with severe brain edema ( fig .
magnetic resonance ( mr ) images revealed that the two lesions were strongly enhanced with cystic change ( fig .
1b , c , f , g ) , and a small round lesion was present in the left head of the caudate nucleus ( fig .
1i ) . the subarachnoid space surrounding the left parietal lesion was also enhanced ( fig .
( 18f ) fluoro-2-deoxyglucose positron emission tomography ( ( 18f ) fdg pet ) exhibited high levels of accumulation in the two large lesions ( fig .
1d , h ) , but revealed no signs of metastatic lesions except in the brain .
a , e : computed tomography images reveal right frontal and left parietal mass lesions .
b , c , f , g : magnetic resonance ( mr ) images show right frontal and left parietal mass lesions as strongly enhanced on t1-weighted image with gadolinium ( b , f ) , and peripheral edema on the t2-weighted image ( c , g ) .
d , h : ( 18f ) fluoro-2-deoxyglucose positron emission tomography images show high accumulations in right frontal and left parietal lesions .
i , j : axial ( i ) and sagittal ( j ) of t1-weighted images with gadolinium revealed an enhanced , small mass lesion in the left head of the caudate nucleus ( i ) , and enhanced subarachnoid space surrounding the left parietal lesion ( j ) .
first , the patient was placed in a prone position . a left parietal craniotomy and a parietal lesion resection were performed .
the patient was then turned to a supine position under general anesthesia , after which a right frontal craniotomy and a frontal lesion resection were performed . both frontal and parietal lesions consisted of soft and fragile black tissues .
both lesions were resected , but the malignant melanoma tissues in the subarachnoid space were residual ( fig .
histological examinations showed typical numerous pleomorphic and hyperchromatic cells , which confirmed the diagnosis of metastatic malignant melanoma .
a , b , c : intraoperative microscopic views show the black malignant melanoma tissues spread in subarachnoid space ( a ) , the border with normal brain was not clear ( b ) , and tumor tissues of subarachnoid space were residual ( c ) .
her consciousness disturbance , right hemiparesis and symptoms of gerstmann syndrome could no longer be seen .
she was discharged to her home 10 days after the operation , almost completely free of neurological deficits .
following surgery , the patient received a course of whole brain radiation therapy consisting of 30 gy in 10 fractions , and chemotherapy at another hospital .
then she presented with pain in her extremities , but there were no signs of bone metastases detected by fdg - pet and bone scintigraphy .
mr images showed a mild enlargement of the left head of the caudate nucleus lesion , but no signs of problems around previous surgical resections ( fig .
spinal mr images revealed a small mass lesion attached to the spinal dura mater at the atlas level ( fig .
the patient presented with a generalized seizure and was again admitted to a nearby hospital .
eventually , she was able to spend time with her family for 3 months at home .
a - c : mr t1-weighted images with gadolinium show mild enlargement of the left head of the caudate nucleus lesion 3 months after the operation ( a ) , but not presenting recurrence as mass lesions at left frontal and right parietal lesions ( b , c ) .
d - f : spinal mr t1-weighted images with gadolinium revealed a small mass lesion attached to spinal dura mater at the atlas level with no signs of spinal cord compression 3 months after operation .
melanomas are the third most common source of intracranial metastases after breast and lung carcinomas .
the incidence of central nervous system ( cns ) metastases in patients with melanomas ranges from 10% to 40% in clinical studies .
cns metastasis is the most worrisome feature of malignant melanoma , leading directly to death in the majority of patients .
the prognosis for patients with malignant melanoma brain metastasis is poor , with a median survival time ranging between 2 to 10 months .
it is noteworthy that only 10% of patients survive more than 1 year after diagnosis .
an important factor strongly influencing the therapeutic response of patients is the number of metastases .
age , sex , and the time interval from the primary malignant melanoma manifestation to the cerebral metastasis seem not to affect the clinical outcome .
prospective randomized trials have demonstrated the benefit of surgery for the treatment of a single metastasis in the brain .
surgical therapy is ordinarily used for the majority of patients with a single metastatic lesion , but only a few selected patients with multiple metastases in the brain are treated surgically .
recently , konstadoulakis et al . reported that the median survival time of surgical resection for multiple brain metastases was 8 months .
they concluded that performing multiple resections of brain metastases from melanoma is considered a radical approach , especially in young patients with well - controlled systemic disease .
the main aim of a simultaneous one - stage resection for multiple metastatic lesions is limited improvement in the quality of the patient s limited remaining life , so the indications are extremely limited .
the two preconditions are that the patients are young and have well - controlled systemic disease , and that dramatic improvements of neurological symptoms may be expected following the resections .
the surgical options for managing two intracranial lesions are influenced by the presence of another intracranial tumor .
when two lesions are contiguous , they may usually be removed using a single approach , but when they are distant from each other , the surgical approach depends upon the type of lesions .
when one tumor is malignant and the other is benign , the malignant tumor must be removed first .
a second craniotomy may be performed at least 10 to 12 months later , when the benign tumor is large enough and/or symptomatic , or shows a tendency to grow .
when the two lesions are malignant , large , or symptomatic tumors , both lesions may require early resection .
in such cases , there is no consensus as to the best surgical management . in the present case ,
therefore , we selected simultaneous one - stage tumor resection with a left parietal craniotomy and a right frontal craniotomy , and found no adverse events associated with the simultaneous one - stage operation .
the patient s surgical position must be changed under general anesthesia , and the operation time is longer , and more invasive .
nevertheless , the significant reduction of intracranial pressure obtained by surgery may produce immediate and dramatic improvements of the patient s neurological symptoms .
the superiority surgical treatment has over radiotherapy for managing multiple metastatic brain tumors is an immediate reduction in intracranial pressure .
while our patient s survival period was not extended , her symptomatic improvements enabled her to return home and spend time with her family . because it improves the quality of the patient s limited remaining life ,
simultaneous one - stage tumor resection using two approaches is a viable option for the surgical management of multiple metastatic brain tumors , especially in young patients with well - controlled systemic disease .
 abstracta 41-year - old woman presented with disturbance of consciousness , right hemiparesis , and symptoms of gerstmann syndrome . 
 she had a history of malignant melanoma resections of an ear mole and her right neck lymph nodes and parotid gland , with subsequent chemotherapy and radiotherapy . 
 computed tomography showed two large lesions in the right frontal and left parietal lobes surrounded by severe brain edema . 
 magnetic resonance images revealed that the two lesions were strongly enhanced with cystic change , and a small round lesion was located in the left head of the caudate nucleus . 
 ( 18f ) fluoro-2-deoxyglucose positron emission tomography showed high accumulation in both lesions , and no sign of metastatic lesions except within the brain . 
 the two lesions were large , causing increased intracranial pressure . 
 simultaneous surgical resections were performed using two approaches . 
 the patient s neurological symptoms were greatly improved after surgery , and her karnofsky performance status improved from 20% to 90% . 
 she was discharged to her home almost completely free of neurological deficits . 
 although , simultaneous one - stage tumor resections for multiple metastatic brain tumors do not extend the survival period , they improve the quality of the patient s limited remaining life , and may be a treatment choice for young patients with well - controlled systemic disease . 
INTRODUCTION
CASE REPORT
DISCUSSION