- Department of Neurosurgery, Georgetown University School of Medicine, Washington DC 20007, USA
Correspondence Address:
M. Nathan Nair
Department of Neurosurgery, Georgetown University School of Medicine, Washington DC 20007, USA
DOI:10.4103/2152-7806.111297
Copyright: © 2013 Yaeger KA This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.How to cite this article: Yaeger KA, Nair MN. Surgery for brain metastases. Surg Neurol Int 02-May-2013;4:
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Abstract
The use of surgery in the treatment of brain metastases is controversial. Patients who present certain clinical characteristics may experience prolonged survival with resection compared with radiation therapy. Thus, for patients with a single metastatic lesion in the setting of well-controlled systemic cancer, surgery is highly indicated. Stereotactic radiosurgery (SRS) alone can provide a similar survival advantage, but when used as postoperative adjuvant therapy, patients experience extended survival times. Furthermore, surgery remains the only treatment option for patients with life-threatening neurological symptoms, who require immediate tumor debulking. Treatment of brain metastases requires a careful clinical assessment of individual patients, as different prognostic factors may indicate various modes or combinations of therapy. Since surgery is an effective method for achieving tumor management in particular cases, it remains an important consideration in the treatment algorithm for brain metastases.
Keywords: Brain metastases, treatment, survival
INTRODUCTION
Metastatic brain cancer represents a growing problem in neurological care. Between 10% and 30% of individuals with systemic cancer will eventually present with brain metastases.[
Brain metastases outnumber primary brain lesions 10 to 1, and as a result, are the most prevalent intracranial tumor.[
The pathophysiology of metastatic spread involves a series of discrete steps, through which a cancer cell must survive in order to gain a foothold at a distant site. Initially, a cancer cell must escape the region of primary tumor and enter systemic circulation through blood, lymph, or cerebrospinal fluid (CSF). The cell consequently undergoes migration to the target site, extravasation, and finally, proliferation within the target tissue. However, survival at each of these steps is constrained by cancer cell genetic and epigenetic alterations, and only 0.01% of cells that make it to circulation will eventually form metastases.[
Typically, patients present with brain metastases after a primary tumor has been diagnosed. It is not uncommon, however, to have synchronous presentation of both a primary and metastatic lesion, or even presentation of the metastasis alone, without an obvious primary lesion. Only two-thirds of patients with brain metastases experience significant neurological symptoms in their lifetimes, the rest being identified as a result of incidental imaging or autopsy studies.[
Treatment of brain metastases depends on several prognostic factors. A worse disease outcome is expected in older patients (≥65 years), worse functional status at diagnosis (Karnofsky Performance Score (KPS) <70), more than one metastatic lesion, and an uncontrolled primary cancer, among others.[
The goal in treating metastatic brain cancer is to maximize survival and functional state while limiting deficits to neurologic status. Currently, much debate is centered on the practice of surgical resection versus stereotactic radiosurgery (SRS) or whole brain radiotherapy (WBRT) for the treatment of brain metastases. Regardless of controversy, however, surgery remains an important consideration in the therapeutic repertoire for metastatic brain cancer, especially for patients with a specific clinical profile.
INDICATIONS FOR SURGERY
Classically, surgical resection of brain metastases has been limited to palliative care. Recently, however, several prospective studies have described a subset of patients for which surgery is highly indicated and results in a prolonged survival.[
In 1990, Patchell et al. compared surgical resection and postoperative WBRT to needle biopsy and radiotherapy for the treatment of a single brain metastasis.[
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.[
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.[
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.[
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).[
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),[
SURGICAL TECHNIQUE
The primary aims for surgical treatment of brain metastases are to improve neurological performance and to prolong overall survival. With the introduction of image-guided and microscopic surgical techniques, these goals have become more readily attainable.[
Control of local recurrence is an important aspect in the management of brain metastases. As many as 46% of resected lesions eventually recur.[
STEREOTACTIC RADIOSURGERY
Stereotactic therapies have arisen as an alternative to traditional surgical resection of metastatic brain lesions, providing a method of noninvasive local control. SRS has been implicated for primary treatment as well as recurrent or adjuvant therapies. For patients who are not surgical candidates due to advanced systemic disease, neurological instability, or presence of multiple metastases, SRS can be used to specifically target lesions, prolonging survival and increasing functional status. Treatment consists of multiple, convergent beam irradiation, delivering high doses to a precise target volume.[
The role of adjuvant SRS in the control of local recurrence following surgical resection is becoming clear. Although WBRT has been traditionally used following surgery, widespread irradiation may cause significant neurotoxicity. Tumor bed SRS has been shown to limit local recurrence and prevent the use of salvage WBRT.[
Due to the nature of radiation therapy, SRS will not immediately relieve mass effect compression or CSF obstruction as caused by a metastatic lesion. For patients with life-threatening neurologic impairments, surgical debulking remains the only option for prompt relief. Another significant indication for the use of surgery over SRS is presence of radioresistant tumor (renal cell carcinoma, sarcoma, melanoma). Potential complications of SRS include seizures, edema, and radiation necrosis.
The controversy whether to treat metastatic lesions with SRS or surgery is well founded. While one retrospective study[
ADJUVANT THERAPY
Although surgery and SRS are effective in maintaining local control of brain metastases, the intracranial spread of these lesions is an issue that may necessitate therapeutic or prophylactic adjuvant therapy. Considering the pathological mechanism of metastatic spread, it is likely that any lesion that may be recognized by CT or MR imaging is not solitary, and there are potentially many micrometastases present. Widespread treatment may be required to eliminate all latent lesions, and has traditionally been given through whole-brain radiation therapy (WBRT). In patients with a limited number of metastases, as treated by either surgery or radiotherapy, follow-up WBRT can reduce the amount of intracranial recurrences and neurologic deaths.[
Although chemotherapeutic treatment for brain tumors may be limited by the blood-brain barrier and initial tumor chemo-resistance, some novel drugs may have some utility in treating extensive brain metastases. Several studies have assessed the impact of intracranial drug delivery following resection. Ewend et al. reported a 0% local recurrence rate after resection of a single metastatic lesion, followed by WBRT and placement of intracavity carmustine polymer wafers.[
CONCLUSION
Assessing a patient with metastatic brain cancer requires thorough clinical consideration and a multimodal approach to therapy. Local tumor control can be maintained through surgical resection or SRS, alone or in combination. Studies have shown that the best survival outcomes are seen in patients with one metastatic lesion, high functional performance, and well-controlled systemic disease, and thus patients fitting this profile may benefit from an aggressive therapy, such as resection and adjuvant SRS of the tumor cavity. Although there are few differences in outcome between surgical resection and SRS, surgery remains as essential therapeutic tool, especially in cases requiring immediate relief from neurological symptoms. As imaging modalities and surgical techniques improve, the role of surgery may become an ever-important method of treatment for metastatic brain cancer.
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