Skip to main content

Advertisement

SpringerLink
Log in

Management of brain metastases: the indispensable role of surgery

  • Topic Review
  • Published:
Journal of Neuro-Oncology Aims and scope Submit manuscript

Abstract

Brain metastases are the most common neurological complication of systemic cancer and carry a very poor prognosis. The management of patients with brain metastases has become more important recently because of the increased incidence of these tumors and the prolonged patient survival times that have accompanied increased control of systemic cancer. In this article, we review the current perspectives on surgical treatment of brain metastases in terms of patient selection criteria, intraoperative adjuncts, whole-brain radiation therapy (WBRT) as a postoperative adjuvant, reoperation for tumor recurrence, and resection of multiple and single metastases. Achieving the best outcome in treatment of brain metastasis requires the judicious and complementary use of surgical resection along with modalities such as whole-brain radiation therapy and stereotactic radiosurgery.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Shaffrey ME, Mut M, Asher AL, Burri SH, Chahlavi A, Chang SM, Farace E, Fiveash JB, Lang FF, Lopes MB, Markert JM, Schiff D, Siomin V, Tatter SB, Vogelbaum MA (2004) Brain metastases. Curr Probl Surg 41:665–741. doi:10.1067/j.cpsurg.2004.06.001

    Article  PubMed  Google Scholar 

  2. Johnson JD, Young B (1996) Demographics of brain metastasis. Neurosurg Clin N Am 7:337–344

    PubMed  CAS  Google Scholar 

  3. Cairncross JG, Posner JB (1983) The management of brain metastases. In: Walker MD (ed) Oncology of the nervous system. Martinus Nijhof, Boston, pp 341–377

  4. Schoggl A, Kitz K, Reddy M, Wolfsberger S, Schneider B, Dieckmann K, Ungersbock K (2000) Defining the role of stereotactic radiosurgery versus microsurgery in the treatment of single brain metastases. Acta Neurochir (Wien) 142:621–626. doi:10.1007/s007010070104

    Article  CAS  Google Scholar 

  5. Schouten LJ, Rutten J, Huveneers HA, Twijnstra A (2002) Incidence of brain metastases in a cohort of patients with carcinoma of the breast, colon, kidney, and lung and melanoma. Cancer 94:2698–2705. doi:10.1002/cncr.10541

    Article  PubMed  Google Scholar 

  6. Kurtz JM, Gelber R, Brady LW, Carella RJ, Cooper JS (1981) The palliation of brain metastases in a favorable patient population: a randomized clinical trial by the Radiation Therapy Oncology Group. Int J Radiat Oncol Biol Phys 7:891–895

    PubMed  CAS  Google Scholar 

  7. Barker FG II (2005) Surgical and radiosurgical management of brain metastases. Surg Clin North Am 85:329–345. doi:10.1016/j.suc.2004.11.003

    Article  PubMed  Google Scholar 

  8. Sundaresan N, Galicich JH (1985) Surgical treatment of brain metastases. Clinical and computerized tomography evaluation of the results of treatment. Cancer 55:1382–1388. doi:10.1002/1097-0142(19850315)55:6<1382::AID-CNCR2820550637>3.0.CO;2-Z

    Article  PubMed  CAS  Google Scholar 

  9. Sundaresan N, Galicich JH, Beattie EJ Jr (1983) Surgical treatment of brain metastases from lung cancer. J Neurosurg 58:666–671

    PubMed  CAS  Google Scholar 

  10. White KT, Fleming TR, Laws ER Jr (1981) Single metastasis to the brain. Surgical treatment in 122 consecutive patients. Mayo Clin Proc 56:424–428

    PubMed  CAS  Google Scholar 

  11. Mandell L, Hilaris B, Sullivan M, Sundaresan N, Nori D, Kim JH, Martini N, Fuks Z (1986) The treatment of single brain metastasis from non-oat cell lung carcinoma. Surgery and radiation versus radiation therapy alone. Cancer 58:641–649

    PubMed  CAS  Google Scholar 

  12. Decker DA, Decker VL, Herskovic A, Cummings GD (1984) Brain metastases in patients with renal cell carcinoma: prognosis and treatment. J Clin Oncol 2:169–173

    PubMed  CAS  Google Scholar 

  13. Barker FG II (2004) Craniotomy for the resection of metastatic brain tumors in the U.S., 1988–2000: decreasing mortality and the effect of provider caseload. Cancer 100:999–1007. doi:10.1002/cncr.20058

    Article  PubMed  Google Scholar 

  14. Patchell RA, Tibbs PA, Walsh JW, Dempsey RJ, Maruyama Y, Kryscio RJ, Markesbery WR, Macdonald JS, Young B (1990) A randomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med 322:494–500

    PubMed  CAS  Google Scholar 

  15. Vecht CJ, Haaxma-Reiche H, Noordijk EM, Padberg GW, Voormolen JH, Hoekstra FH, Tans JT, Lambooij N, Metsaars JA, Wattendorff AR et al (1993) Treatment of single brain metastasis: radiotherapy alone or combined with neurosurgery? Ann Neurol 33:583–590. doi:10.1002/ana.410330605

    Article  PubMed  CAS  Google Scholar 

  16. Black PM (1993) Solitary brain metastases. Radiation, resection, or radiosurgery? Chest 103:367S–369S. doi:10.1378/chest.103.4_Supplement.367S

    Article  PubMed  CAS  Google Scholar 

  17. Bindal AK, Bindal RK, Hess KR, Shiu A, Hassenbusch SJ, Shi WM, Sawaya R (1996) Surgery versus radiosurgery in the treatment of brain metastasis. J Neurosurg 84:748–754

    PubMed  CAS  Google Scholar 

  18. Auchter RM, Lamond JP, Alexander E, Buatti JM, Chappell R, Friedman WA, Kinsella TJ, Levin AB, Noyes WR, Schultz CJ, Loeffler JS, Mehta MP (1996) A multiinstitutional outcome and prognostic factor analysis of radiosurgery for resectable single brain metastasis. Int J Radiat Oncol Biol Phys 35:27–35. doi:10.1016/S0360-3016(96)85008-5

    PubMed  CAS  Google Scholar 

  19. Muacevic A, Wowra B, Siefert A, Tonn JC, Steiger HJ, Kreth FW (2008) Microsurgery plus whole brain irradiation versus Gamma Knife surgery alone for treatment of single metastases to the brain: a randomized controlled multicentre phase III trial. J Neurooncol 87:299–307. doi:10.1007/s11060-007-9510-4

    Article  PubMed  Google Scholar 

  20. Lang FF, Suki D, Maor M, Chang E, Hess K, Graham S, Hentschel S, Sawaya R (2008) Conventional surgery versus stereotactic radiosurgery in the treatment of single brain metastases: a prospective study with both randomized and nonrandomized arms. American Association of Neurological Surgeons Meeting [abstract]:Article ID: 48938

  21. Moazami N, Rice TW, Rybicki LA, Adelstein DJ, Murthy SC, DeCamp MM, Barnett GH, Chidel MA, Suh JH, Blackstone EH (2002) Stage III non-small cell lung cancer and metachronous brain metastases. J Thorac Cardiovasc Surg 124:113–122. doi:10.1067/mtc.2002.121678

    Article  PubMed  Google Scholar 

  22. Schag CC, Heinrich RL, Ganz PA (1984) Karnofsky performance status revisited: reliability, validity, and guidelines. J Clin Oncol 2:187–193

    PubMed  CAS  Google Scholar 

  23. Gaspar L, Scott C, Rotman M, Asbell S, Phillips T, Wasserman T, McKenna WG, Byhardt R (1997) Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy Oncology Group (RTOG) brain metastases trials. Int J Radiat Oncol Biol Phys 37:745–751. doi:10.1016/S0360-3016(96)00619-0

    PubMed  CAS  Google Scholar 

  24. Agboola O, Benoit B, Cross P, Da Silva V, Esche B, Lesiuk H, Gonsalves C (1998) Prognostic factors derived from recursive partition analysis (RPA) of Radiation Therapy Oncology Group (RTOG) brain metastases trials applied to surgically resected and irradiated brain metastatic cases. Int J Radiat Oncol Biol Phys 42:155–159. doi:10.1016/S0360-3016(98)00198-9

    PubMed  CAS  Google Scholar 

  25. Chidel MA, Suh JH, Reddy CA, Chao ST, Lundbeck MF, Barnett GH (2000) Application of recursive partitioning analysis and evaluation of the use of whole brain radiation among patients treated with stereotactic radiosurgery for newly diagnosed brain metastases. Int J Radiat Oncol Biol Phys 47:993–999. doi:10.1016/S0360-3016(00)00527-7

    PubMed  CAS  Google Scholar 

  26. Posner JB (1977) Management of central nervous system metastases. Semin Oncol 4:81–91

    PubMed  CAS  Google Scholar 

  27. Gaspar LE, Scott C, Murray K, Curran W (2000) Validation of the RTOG recursive partitioning analysis (RPA) classification for brain metastases. Int J Radiat Oncol Biol Phys 47:1001–1006. doi:10.1016/S0360-3016(00)00547-2

    PubMed  CAS  Google Scholar 

  28. Saitoh Y, Fujisawa T, Shiba M, Yoshida S, Sekine Y, Baba M, Iizasa T, Kubota M (1999) Prognostic factors in surgical treatment of solitary brain metastasis after resection of non-small-cell lung cancer. Lung Cancer 24:99–106. doi:10.1016/S0169-5002(99)00034-3

    Article  PubMed  CAS  Google Scholar 

  29. Salvati M, Capoccia G, Orlando ER, Fiorenza F, Gagliardi FM (1992) Single brain metastases from breast cancer: remarks on clinical pattern and treatment. Tumori 78:115–117

    PubMed  CAS  Google Scholar 

  30. Lagerwaard FJ, Levendag PC, Nowak PJ, Eijkenboom WM, Hanssens PE, Schmitz PI (1999) Identification of prognostic factors in patients with brain metastases: a review of 1292 patients. Int J Radiat Oncol Biol Phys 43:795–803. doi:10.1016/S0360-3016(98)00442-8

    PubMed  CAS  Google Scholar 

  31. Galicich JH, Sundaresan N, Arbit E, Passe S (1980) Surgical treatment of single brain metastasis: factors associated with survival. Cancer 45:381–386. doi:10.1002/1097-0142(19800115)45:2<381::AID-CNCR2820450232>3.0.CO;2-J

    Article  PubMed  CAS  Google Scholar 

  32. Pieper DR, Hess KR, Sawaya RE (1997) Role of surgery in the treatment of brain metastases in patients with breast cancer. Ann Surg Oncol 4:481–490. doi:10.1007/BF02303672

    Article  PubMed  CAS  Google Scholar 

  33. Korinth MC, Delonge C, Hutter BO, Gilsbach JM (2002) Prognostic factors for patients with microsurgically resected brain metastases. Onkologie 25:420–425. doi:10.1159/000067435

    Article  PubMed  CAS  Google Scholar 

  34. Mintz AH, Kestle J, Rathbone MP, Gaspar L, Hugenholtz H, Fisher B, Duncan G, Skingley P, Foster G, Levine M (1996) A randomized trial to assess the efficacy of surgery in addition to radiotherapy in patients with a single cerebral metastasis. Cancer 78:1470–1476. doi:10.1002/(SICI)1097-0142(19961001)78:7<1470::AID-CNCR14>3.0.CO;2-X

    Article  PubMed  CAS  Google Scholar 

  35. Weinberg JS, Lang FF, Sawaya R (2001) Surgical management of brain metastases. Curr Oncol Rep 3:476–483. doi:10.1007/s11912-001-0068-6

    Article  PubMed  CAS  Google Scholar 

  36. Patchell RA, Tibbs PA, Regine WF, Dempsey RJ, Mohiuddin M, Kryscio RJ, Markesbery WR, Foon KA, Young B (1998) Postoperative radiotherapy in the treatment of single metastases to the brain: a randomized trial. JAMA 280:1485–1489. doi:10.1001/jama.280.17.1485

    Article  PubMed  CAS  Google Scholar 

  37. Kelly K, Bunn PA Jr (1998) Is it time to reevaluate our approach to the treatment of brain metastases in patients with non-small cell lung cancer? Lung Cancer 20:85–91. doi:10.1016/S0169-5002(98)00020-8

    Article  PubMed  CAS  Google Scholar 

  38. Paek SH, Audu PB, Sperling MR, Cho J, Andrews DW (2005) 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 56:1021–1034

    PubMed  Google Scholar 

  39. Bindal RK, Sawaya R, Leavens ME, Lee JJ (1993) Surgical treatment of multiple brain metastases. J Neurosurg 79:210–216

    PubMed  CAS  Google Scholar 

  40. Wronski M, Arbit E, McCormick B, Wronski M (1997) Surgical treatment of 70 patients with brain metastases from breast carcinoma. Cancer 80:1746–1754. Published erratum appears in Cancer 1998 Feb 15;82(4):following 800. doi:10.1002/(SICI)1097-0142(19971101)80:9<1746::AID-CNCR8>3.0.CO;2-C

    Google Scholar 

  41. Stark AM, Tscheslog H, Buhl R, Held-Feindt J, Mehdorn HM (2005) Surgical treatment for brain metastases: prognostic factors and survival in 177 patients. Neurosurg Rev 28:115–119. doi:10.1007/s10143-004-0364-3

    Article  PubMed  Google Scholar 

  42. Arbit E, Wronski M, Burt M, Galicich JH (1995) The treatment of patients with recurrent brain metastases. A retrospective analysis of 109 patients with nonsmall cell lung cancer. Cancer 76:765–773. doi:10.1002/1097-0142(19950901)76:5<765::AID-CNCR2820760509>3.0.CO;2-E

    Article  PubMed  CAS  Google Scholar 

  43. Bindal RK, Sawaya R, Leavens ME, Hess KR, Taylor SH (1995) Reoperation for recurrent metastatic brain tumors. J Neurosurg 83:600–604

    Article  PubMed  CAS  Google Scholar 

  44. Wadley J, Dorward N, Kitchen N, Thomas D (1999) Pre-operative planning and intra-operative guidance in modern neurosurgery: a review of 300 cases. Ann R Coll Surg Engl 81:217–225

    PubMed  CAS  Google Scholar 

  45. Tan TC, Black PM (2003) Image-guided craniotomy for cerebral metastases: techniques and outcomes. Neurosurgery 53:82–90. doi:10.1227/01.NEU.0000068729.37362.F9

    Article  PubMed  Google Scholar 

  46. Landy HJ, Egnor M (1991) Intraoperative ultrasonography and cortical mapping for removal of deep cerebral tumors. South Med J 84:1323–1326

    PubMed  CAS  Google Scholar 

  47. Kondziolka D, Lunsford LD (1993) Brain metastases. In: Apuzzo MLJ (ed) Brain surgery: complication avoidance and management. Churchill Livingstone, New York, pp 615–641

  48. Neves S, Mazal PR, Wanschitz J, Rudnay AC, Drlicek M, Czech T, Wustinger C, Budka H (2001) Pseudogliomatous growth pattern of anaplastic small cell carcinomas metastatic to the brain. Clin Neuropathol 20:38–42

    PubMed  CAS  Google Scholar 

  49. Baumert BG, Rutten I, Dehing-Oberije C, Twijnstra A, Dirx MJ, Debougnoux-Huppertz RM, Lambin P, Kubat B (2006) A pathology-based substrate for target definition in radiosurgery of brain metastases. Int J Radiat Oncol Biol Phys 66:187–194. doi:10.1016/j.ijrobp.2006.03.050

    PubMed  Google Scholar 

  50. Yoo H, Kim YZ, Nam BH, Shin SH, Yang HS, Lee JS, Zo JI, Lee SH (2008) Reduced local recurrence of a single brain metastasis through microscopic total resection. J Neurosurg. doi:10.3171/2008.8.JNS08448

    PubMed  Google Scholar 

  51. Suki D, Abouassi H, Patel AJ, Sawaya R, Weinberg JS, Groves MD (2008) Comparative risk of leptomeningeal disease after resection or stereotactic radiosurgery for solid tumor metastasis to the posterior fossa. J Neurosurg 108:248–257. doi:10.3171/JNS/2008/108/2/0248

    Article  PubMed  Google Scholar 

  52. Patel AJ, Suki D, Hatiboglu MA, Abouassi H, Lang FF, Sawaya RE (2008) Factors influencing the risk of local recurrence following resection of a single brain metastasis. Congress of Neurological Surgeons Annual Meeting: Abstract 872

  53. Sawaya R, Wildrick DM (2008) Metastatic brain tumors: surgery perspective. In: Chin L, Regine W (eds) Principles and practice of stereotactic radiosurgery. Springer-Verlag, Heidelberg, Germany, pp 193–199

  54. Sawaya R (1999) Surgical treatment of brain metastases. Clin Neurosurg 45:41–47

    PubMed  CAS  Google Scholar 

  55. Mehta MP, Rozental JM, Levin AB, Mackie TR, Kubsad SS, Gehring MA, Kinsella TJ (1992) Defining the role of radiosurgery in the management of brain metastases. Int J Radiat Oncol Biol Phys 24:619–625

    PubMed  CAS  Google Scholar 

  56. Chang EL, Hassenbusch SJ III, Shiu AS, Lang FF, Allen PK, Sawaya R, Maor MH (2003) The role of tumor size in the radiosurgical management of patients with ambiguous brain metastases. Neurosurgery 53:272–280. doi:10.1227/01.NEU.0000073546.61154.9A

    Article  PubMed  Google Scholar 

  57. Regine WF, Huhn JL, Patchell RA, St. Clair WH, Strottmann J, Meigooni A, Sanders M, Young AB (2002) Risk of symptomatic brain tumor recurrence and neurologic deficit after radiosurgery alone in patients with newly diagnosed brain metastases: results and implications. Int J Radiat Oncol Biol Phys 52:333–338. doi:10.1016/S0360-3016(01)02645-1

  58. Dare AO, Sawaya R (2004) Part II: Surgery versus radiosurgery for brain metastasis: surgical advantages and radiosurgical myths. Clin Neurosurg 51:255–263

    PubMed  Google Scholar 

Download references

Acknowledgment

We thank David M. Wildrick, Ph.D., for editorial assistance with this manuscript.

Author information

Authors and Affiliations

  1. Departments of Neurosurgery, Baylor College of Medicine and The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA

    George Al-Shamy & Raymond Sawaya

Authors
  1. George Al-Shamy
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Raymond Sawaya
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Raymond Sawaya.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Al-Shamy, G., Sawaya, R. Management of brain metastases: the indispensable role of surgery. J Neurooncol 92, 275–282 (2009). https://doi.org/10.1007/s11060-009-9839-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11060-009-9839-y

Keywords

Search

Navigation