Management of brain metastases: the indispensable role of surgery

Topic Review


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.


Brain metastases Surgery Resection 


  1. 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 PubMedCrossRefGoogle Scholar
  2. 2.
    Johnson JD, Young B (1996) Demographics of brain metastasis. Neurosurg Clin N Am 7:337–344PubMedGoogle Scholar
  3. 3.
    Cairncross JG, Posner JB (1983) The management of brain metastases. In: Walker MD (ed) Oncology of the nervous system. Martinus Nijhof, Boston, pp 341–377Google Scholar
  4. 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 CrossRefGoogle Scholar
  5. 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 PubMedCrossRefGoogle Scholar
  6. 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 7:891–895PubMedGoogle Scholar
  7. 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 PubMedCrossRefGoogle Scholar
  8. 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 PubMedCrossRefGoogle Scholar
  9. 9.
    Sundaresan N, Galicich JH, Beattie EJ Jr (1983) Surgical treatment of brain metastases from lung cancer. J Neurosurg 58:666–671PubMedGoogle Scholar
  10. 10.
    White KT, Fleming TR, Laws ER Jr (1981) Single metastasis to the brain. Surgical treatment in 122 consecutive patients. Mayo Clin Proc 56:424–428PubMedGoogle Scholar
  11. 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 58:641–649PubMedGoogle Scholar
  12. 12.
    Decker DA, Decker VL, Herskovic A, Cummings GD (1984) Brain metastases in patients with renal cell carcinoma: prognosis and treatment. J Clin Oncol 2:169–173PubMedGoogle Scholar
  13. 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 PubMedCrossRefGoogle Scholar
  14. 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 322:494–500PubMedGoogle Scholar
  15. 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 PubMedCrossRefGoogle Scholar
  16. 16.
    Black PM (1993) Solitary brain metastases. Radiation, resection, or radiosurgery? Chest 103:367S–369S. doi:10.1378/chest.103.4_Supplement.367S PubMedCrossRefGoogle Scholar
  17. 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 84:748–754PubMedGoogle Scholar
  18. 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 PubMedGoogle Scholar
  19. 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 PubMedCrossRefGoogle Scholar
  20. 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: 48938Google Scholar
  21. 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 PubMedCrossRefGoogle Scholar
  22. 22.
    Schag CC, Heinrich RL, Ganz PA (1984) Karnofsky performance status revisited: reliability, validity, and guidelines. J Clin Oncol 2:187–193PubMedGoogle Scholar
  23. 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 PubMedGoogle Scholar
  24. 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 PubMedGoogle Scholar
  25. 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 PubMedGoogle Scholar
  26. 26.
    Posner JB (1977) Management of central nervous system metastases. Semin Oncol 4:81–91PubMedGoogle Scholar
  27. 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 PubMedGoogle Scholar
  28. 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 PubMedCrossRefGoogle Scholar
  29. 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 78:115–117PubMedGoogle Scholar
  30. 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 PubMedGoogle Scholar
  31. 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 PubMedCrossRefGoogle Scholar
  32. 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 PubMedCrossRefGoogle Scholar
  33. 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 PubMedCrossRefGoogle Scholar
  34. 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 PubMedCrossRefGoogle Scholar
  35. 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 PubMedCrossRefGoogle Scholar
  36. 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 PubMedCrossRefGoogle Scholar
  37. 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 PubMedCrossRefGoogle Scholar
  38. 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 56:1021–1034PubMedGoogle Scholar
  39. 39.
    Bindal RK, Sawaya R, Leavens ME, Lee JJ (1993) Surgical treatment of multiple brain metastases. J Neurosurg 79:210–216PubMedGoogle Scholar
  40. 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. 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 PubMedCrossRefGoogle Scholar
  42. 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 PubMedCrossRefGoogle Scholar
  43. 43.
    Bindal RK, Sawaya R, Leavens ME, Hess KR, Taylor SH (1995) Reoperation for recurrent metastatic brain tumors. J Neurosurg 83:600–604PubMedCrossRefGoogle Scholar
  44. 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 81:217–225PubMedGoogle Scholar
  45. 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 PubMedCrossRefGoogle Scholar
  46. 46.
    Landy HJ, Egnor M (1991) Intraoperative ultrasonography and cortical mapping for removal of deep cerebral tumors. South Med J 84:1323–1326PubMedGoogle Scholar
  47. 47.
    Kondziolka D, Lunsford LD (1993) Brain metastases. In: Apuzzo MLJ (ed) Brain surgery: complication avoidance and management. Churchill Livingstone, New York, pp 615–641Google Scholar
  48. 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 20:38–42PubMedGoogle Scholar
  49. 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 PubMedGoogle Scholar
  50. 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 PubMedGoogle Scholar
  51. 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 PubMedCrossRefGoogle Scholar
  52. 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 872Google Scholar
  53. 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 193–199Google Scholar
  54. 54.
    Sawaya R (1999) Surgical treatment of brain metastases. Clin Neurosurg 45:41–47PubMedGoogle Scholar
  55. 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 24:619–625PubMedGoogle Scholar
  56. 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 PubMedCrossRefGoogle Scholar
  57. 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. 58.
    Dare AO, Sawaya R (2004) Part II: Surgery versus radiosurgery for brain metastasis: surgical advantages and radiosurgical myths. Clin Neurosurg 51:255–263PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC. 2009

Authors and Affiliations

  1. 1.Departments of NeurosurgeryBaylor College of Medicine and The University of Texas M. D. Anderson Cancer CenterHoustonUSA

Personalised recommendations