Surgical Management of Brain Metastases

Moksha G. Ranasinghe, M.D.; Jonas M. Sheehan, M.D.

Disclosures

Neurosurg Focus. 2007;22(3) 

In This Article

Abstract and Introduction

Metastatic brain tumors continue to increase in incidence as patients with cancer live longer. The options for management continue to evolve as well, with advances in radiation-based treatment, chemotherapy, and surgery. Although metastatic brain tumors are frequently treated without surgical intervention, there continues to be a significant role for surgery in caring for patients with these lesions. Study data have proven that surgery has a positive effect on survival and quality of life in properly selected patients. Those with a suitable age, functional status, systemic disease control, and several metastases may be suitable for surgical treatment. Advances in preoperative imaging and planning as well as intraoperative surgical adjuncts have lowered the morbidity associated with resection. With proper patient selection and operative and postoperative management, resection continues to play a significant and evolving role in the care of patients with metastatic brain tumor.

Metastatic brain tumors are diagnosed in nearly 150,000 patients annually in the US, arising in 10 to 40% of patients with cancer.[15] The most common primary sources of brain metastases are lung (17%), renal cell (10.5%), and breast (5.2%) cancer and melanoma (8%).[31] With the increase in the early detection of primary tumors and longer survival in patients with cancer, the incidence of brain metastases is rising. Improvements in imaging quality and accessibility have also contributed to the increased number of patients in whom metastasis is diagnosed. Modern imaging technology can detect smaller lesions, allowing for earlier intervention than was possible in the past and perhaps increasing the opportunity to control CNS disease. The majority of patients who have local CNS tumor control die of extracranial disease progression, whereas those with uncontrolled brain metastases more often die of neurological causes.[2] Therefore, achieving local control is of primary importance when considering treatment options in patients with brain metastases.[42]

Because of its less invasive nature and apparent effectiveness for metastatic disease, stereotactic radiosurgery is chosen over resection with increasing frequency. How ever, surgical removal is a mainstay in the treatment of brain metastases. Advances in surgical techniques permit re section with decreasing morbidity, thus making re sect able certain metastases that were previously considered unresectable. Such advances improved surgical access to metastases and allowed more aggressive resections with correspondingly low surgical complications and morbidity.

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