Intracranial metastases surgery indications [Neurosurgery Wiki]

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====== Intracranial metastases surgery indications ======

{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1la0KilYwPOCHwAPazngqu9ta8gz0VbLYKPb7wyUtrqtkpe9it/?limit=15&utm_campaign=pubmed-2&fc=20230118163836}}
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Indicated in:

Solitary lesion causing mass effect

Diagnostic uncertainty

Accessible location

Good performance status

Often followed by SRS to the cavity.

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Neurosurgical procedures are of central importance in the multimodal treatment of cerebral metastases. The indications for neurosurgical interventions will be refined in the light of more effective radiation techniques and systemic treatments with new targeted therapeutic approaches and immunotherapies on the horizon
((Thon N, Karschnia P, Baumgarten LV, Niyazi M, Steinbach JP, Tonn JC. Neurosurgical Interventions for Cerebral Metastases of Solid Tumors. Dtsch Arztebl Int. 2023 Mar 10;(Forthcoming):arztebl.m2022.0410. doi: 10.3238/arztebl.m2022.0410. Epub ahead of print. PMID: 36650742.)).
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For [[patient]]s who develop [[brain metastases]] from [[solid tumor]]s, [[age]], [[KPS]], primary tumor status and presence of [[extracranial metastases]] have been identified as prognostic factors. However, the factors that affect [[survival]] in patients who are deemed fit to undergo [[resection]] of [[brain metastases]] have not been clearly elucidated hitherto.

In a retrospective analysis of a [[prospective]]ly maintained [[database]]. All patients who underwent resection of [[intracranial metastases]] from solid tumors were included. Various patient, disease and treatment-related factors were analyzed to assess their impact on survival.

Overall, 124 patients had undergone surgery for brain metastases from various primary sites. The median age and pre-operative performance scores were 53 years and 80 respectively. Synchronous metastases were resected in 17.7% of the patients. The postoperative morbidity and mortality rates were 17.7% and 2.4% respectively. Adjuvant whole-brain radiation was received by 64 patients. At last follow-up, 8.1% of patients had fresh post-surgical neurologic deficits. The median progression-free and overall survival were 6.91 was 8.56 months respectively.

Surgical resection of for brain metastases should be considered in carefully selected patients. Gross total resection and receiving adjuvant whole brain RT significantly improves survival in these patients
((Sivasanker M, Madhugiri VS, Moiyadi AV, Shetty P, Subi TS. Surgery for brain
metastases: An analysis of outcomes and factors affecting survival. Clin Neurol
Neurosurg. 2018 Mar 10;168:153-162. doi: 10.1016/j.clineuro.2018.03.011. [Epub
ahead of print] PubMed PMID: 29554624.
)).

Several prospective studies have described a subset of patients for which surgery is highly indicated and results in a prolonged survival
((Vogelbaum MA, Suh JH. Resectable [[brain metastases]]. J Clin Oncol. 2006 Mar
10;24(8):1289-94. Review. PubMed PMID: 16525184.
)).

These patients most often have a single, surgically accessible metastatic lesion, absent or well-controlled systemic disease, good functional status ([[KPS]]), intact neurological function, and absence of leptomeningeal infiltration
((Yaeger KA, Nair MN. Surgery for brain metastases. Surg Neurol Int. 2013 May
2;4(Suppl 4):S203-8. doi: 10.4103/2152-7806.111297. Print 2013. PubMed PMID:
23717791; PubMed Central PMCID: PMC3656566.
)).

In 1990, Patchell et al. compared surgical resection and postoperative WBRT to needle biopsy and radiotherapy for the treatment of a single brain metastasis
((Patchell RA, Tibbs PA, Walsh JW, Dempsey RJ, Maruyama Y, Kryscio RJ,
Markesbery WR, Macdonald JS, Young B. A randomized trial of surgery in the
treatment of single metastases to the brain. N Engl J Med. 1990 Feb
22;322(8):494-500. PubMed PMID: 2405271.
)).

In this seminal work, the authors described surgically treated individuals as having a longer survival period (40 weeks, compared with 15 weeks), greater functional independence, and decreased incidence of recurrence within the original metastatic site. A similar study by Vecht et al. in 1993 yielded analogous results, but the authors noted that extended survival with surgery only applied to patients with stable extracranial disease
((Vecht CJ, Haaxma-Reiche H, Noordijk EM, Padberg GW, Voormolen JH, Hoekstra FH,
Tans JT, Lambooij N, Metsaars JA, Wattendorff AR, et al. Treatment of single
brain metastasis: radiotherapy alone or combined with neurosurgery? Ann Neurol.
1993 Jun;33(6):583-90. PubMed PMID: 8498838.
)).

The presence of a single metastatic lesion in the setting of well-controlled systemic cancer is the best indicator for surgical therapy, and is predictive for prolonged survival following resection. Furthermore, patients who improve functionally after surgery tend to experience better outcomes in response to adjuvant therapy
((Mut M. Surgical treatment of brain metastasis: a review. Clin Neurol
Neurosurg. 2012 Jan;114(1):1-8. doi: 10.1016/j.clineuro.2011.10.013. Epub 2011
Nov 1. Review. PubMed PMID: 22047649.
)).

For lesions causing significant neurological complications, the role of surgery is definitive: Tumor resection remains the only effective method of providing immediate relief to life threatening symptoms
((Moser RP, Johnson ML. Surgical management of brain metastases: how aggressive 
should we be? Oncology (Williston Park). 1989 Jun;3(6):123-7; discussion 128,
134. Review. PubMed PMID: 2484296.
)).

Surgical extirpation can alleviate symptoms associated with mass effect, intracranial hypertension secondary to CSF obstruction, and peritumoral edema
((Thomas SS, Dunbar EM. Modern multidisciplinary management of brain metastases.
Curr Oncol Rep. 2010 Jan;12(1):34-40. doi: 10.1007/s11912-009-0073-8. Review.
PubMed PMID: 20425606.
)).

Patients experiencing medically refractory seizures, as induced by a metastatic lesion, may similarly benefit from surgery
((Ranasinghe MG, Sheehan JM. Surgical management of brain metastases. Neurosurg 
Focus. 2007 Mar 15;22(3):E2. Review. PubMed PMID: 17608355.
)).

Because large tumors are most likely to cause significant neurological complications, lesion size greater than 3 cm is an indication for surgery
((Narita Y, Shibui S. Strategy of surgery and radiation therapy for brain
metastases. Int J Clin Oncol. 2009 Aug;14(4):275-80. doi:
10.1007/s10147-009-0917-0. Epub 2009 Aug 25. Review. PubMed PMID: 19705236.
)).

Cerebellar lesions are also a surgical indication, as they often present with brainstem compression and obstructive hydrocephalus, necessitating immediate resection
((Narita Y, Shibui S. Strategy of surgery and radiation therapy for brain
metastases. Int J Clin Oncol. 2009 Aug;14(4):275-80. doi:
10.1007/s10147-009-0917-0. Epub 2009 Aug 25. Review. PubMed PMID: 19705236.
)).

For patients with end stage metastatic disease, surgery may represent an effective salvage therapy. Surgical intervention may be required to reduce mass effect or CSF obstruction, and may ameliorate impaired consciousness and improve neurologic function
((Sandberg DI, Bilsky MH, Souweidane MM, Bzdil J, Gutin PH. Ommaya reservoirs
for the treatment of leptomeningeal metastases. Neurosurgery. 2000
Jul;47(1):49-54; discussion 54-5. PubMed PMID: 10917346.
)).

A principle contraindication to surgical treatment of brain metastases is the presence of multiple lesions. Although some appropriately selected patients may benefit from aggressive multimodal therapy, surgery may not improve the already short expected survival, and is thus hard to justify
((Pollock BE, Brown PD, Foote RL, Stafford SL, Schomberg PJ. Properly selected
patients with multiple brain metastases may benefit from aggressive treatment of 
their intracranial disease. J Neurooncol. 2003 Jan;61(1):73-80. Review. PubMed
PMID: 12587798.
)).

Additionally, the technical difficulties in accessing and resecting multiple lesions limit the potential benefits of surgery. In cases where there exists a large dominant lesion, however, surgery may be indicated to provide symptomatic relief
((Narita Y, Shibui S. Strategy of surgery and radiation therapy for brain
metastases. Int J Clin Oncol. 2009 Aug;14(4):275-80. doi:
10.1007/s10147-009-0917-0. Epub 2009 Aug 25. Review. PubMed PMID: 19705236.
)).

Reoperation for recurrent brain metastases may be indicated in certain situations. Bindal et al. reported an increased survival time for patients whose recurrent metastases were resected, versus those who did not undergo additional operations (8.6 and 2.8 months, respectively)
((Bindal RK, Sawaya R, Leavens ME, Hess KR, Taylor SH. Reoperation for recurrent
metastatic brain tumors. J Neurosurg. 1995 Oct;83(4):600-4. PubMed PMID: 7674007.
)).

Patients with well-controlled systemic disease and high performance scores may indeed experience better survival after sequential surgeries for recurrences. Surgical resection is certainly a viable option for treating tumor recurrence after SRS, unless surgery is otherwise contraindicated
((Truong MT, St Clair EG, Donahue BR, Rush SC, Miller DC, Formenti SC, Knopp EA,
Han K, Golfinos JG. Results of surgical resection for progression of brain
metastases previously treated by gamma knife radiosurgery. Neurosurgery. 2006
Jul;59(1):86-97; discussion 86-97. PubMed PMID: 16823304.
)).

Proceeding with surgery depends entirely on the individual patient's clinical scenario. Patients with a single metastatic lesion and well-controlled primary cancer experience improvements in neurological function and lengthened survival time following resection. Since rates of surgical mortality and neurological morbidity are low (under 2% and 6%, respectively),
((Paek SH, Audu PB, Sperling MR, Cho J, Andrews DW. Reevaluation of surgery for 
the treatment of brain metastases: review of 208 patients with single or multiple
brain metastases treated at one institution with modern neurosurgical techniques.
Neurosurgery. 2005 May;56(5):1021-34; discussion 1021-34. PubMed PMID: 15854250.
))
surgery remains a feasible option for the treatment of brain metastases.

===== References =====