Case 1

TB DOB 27/6/1947 First presentation : 24/10/2002 3 months personality changes Left facial droop Unsteady gait Progressive headache

H/o HTN/Left knee surgery ETOH occasional non smoker CT brain : three intracranial lesions (rt .frontal,rt.frontoparietal and left parietooccipital) Operated on24/10/2002 two craniotomies (left parieto-occipital and right frontoparietal) HPE : Met. Melanoma

 17/10/02 Ct scan chest small lung lesion noted Seen by radiation oncology team advised WBRT (30Gy in 10 fractions over 2 weeks) Completed RT by Jan/2003

Developed pigmented lesion over left Ear operated Mar/2003 consistent of Melanoma

 On follow up scans recurrence of cerebral lesion (right) noted Reoperated and recurrence was excised 14/8/2003 CT body scan August- 2003 no lesions noted Nov/2003 rt.adrenal gland lesion noted Feb/2004 rt adrenal lesion size increased Mar/2004 PET studies revealed Left lung peripheral lesion noted

April/2004 had Adrenal resection July /2004 Lung resection Feb/2005 presented in confused state CT/MRI showed left frontoparital solitary lesion surgery thought less beneficial Had SRS for the lesion March/2005 Progression in dyphasia and unsteady gait operated July/2005 Hemiparetic following surgery needed rehab.

 March/2006 MRI brain ? Rt frontal lesion CT chest/abd/pelvis No obvious lesions noted August/2006 palliative team visited at home no surgical/medical options

Case 2
MD DOB 3/2/1951 First presentation June/2005 Presented to ED for wondering in confused state in supermarket CT brain large right parietal tumor noted Operated on 1/6/2005

 HPE consistent with Melanoma Noted to have skin lesion on left upper arm confirmed as Melanoma No family h/o cancer Non smoker/No ETOH July/2005 not keen to have RT Readmitted for headaches CT brain Recurrence at previous surgical site

 CT/MRI brain showed recurrence Operated in October/2005 HPE poorly differentiated large cell tumor Palliative RT (whole brain ) April/2006 MRI brain clear of any recurrence June/2006 advanced metastatic disease through out his lymph nodes in rt.axilla/mediastinum/abd with massive liver involvement and small lung lesion

 July/2006 DTIC two cycles completed no response

Case 3
BJ DOB 4/3/1941 First admission Feb/2005 Presented with headache 12 months Seizure 3weeks prior to admission MRI brain- cerebral lesion

 No smoking for last 10 years (before 30pack) ETOH I std/day Mother died of stoke at age 63 Father died of brain tumor aged 55 One brother died of Ca.prostate (70) One brother died of oesophageal Ca (73) One brother died of Leukaemia (620

Past h/o Crohns disease AMI 1995 Asthma/COPD/HTN

 Operated in Feb/2005 total excision HPE metastatic lesion consistent with clear cell carcinoma Feb/2005 Left renal cell carcinoma and single lung lesion in left lower lobe 1.5 cm Medical oncology team plan:to keep extracranial disease under surveillance Cancer service felt family pattern does not fit strong inheritance susceptibility

 May/2005follow up CT confirmed presence of 3 lung Mets.in left lung lower zone Clinically no symptoms Close watch of the disease planned

Jan/2006 asymptomatic with primary Renal and secondary lung lesion Follow up CT in 3-6 months

 Represented Feb/2007 with headache Ct brain Vermian lesion