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Delayed surgical resections of brain metastases after gamma knife radiosurgery

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Abstract

Although brain metastases are one of the most frequently diagnosed sequelae of systemic malignancy, their optimal management still is not well defined. In that respect, the different diagnostic and therapeutic approaches of BMs patients is an issue for serious discussions. The treatment options include surgical excision, WBRT, radiosurgery, chemotherapy, immunotherapy, etc. Nowadays, the aforementioned treatment modalities are usually combined in different treatment schemes. More than one option is used for the same patient and combining these treatment modalities gives better results than when separately use them. The value of surgical excision of progressing brain metastases treated with gamma knife surgery (GKS) is not well investigated.With the present study, we aim to investigate the value of surgical excision of symptomatic brain lesions that have been previously treated with GKS.

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Author notes

  1. Nikolay A. Peev

    Present address: Department of Neurosurgery, Medical University of Varna, 55 Marin Drinov Str., Varna, 9002, Bulgaria

Authors and Affiliations

  1. Department of Neurosurgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, 470-1192, Japan

    Nikolay A. Peev, Yuichi Hirose, Shinya Nagahisa, Testuo Kanno & Hirotoshi Sano

  2. Department of Neurosurgery, Fujieda Heisei Memorial Hospital, Fujieda, Japan

    Tatsuo Hirai & Yuya Nishiyama

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  1. Nikolay A. Peev
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  2. Yuichi Hirose
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Correspondence to Yuichi Hirose.

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Comments

Takeshi Kawase, Tokyo, Japan

Differential diagnosis between tumor regrow and radiation necrosis are commonly obscured after radiosurgery even by means of PET and MRS. However, the diagnosis may absolutely influential on the patient's survival in a case the primary lesion was controlled.

This paper gave a very important pathological data on 13 patients, that it is not only the massive necrosis but include viable cancer cells in all the cases. This means the patients could not survive without an additional surgery. In their data, it is clear that five of 13 patients were rescued by an additional surgery. Neurosurgeons should not hesitate for the additional surgical remove of the symptomatic growing mass, even in a case of the diagnosis being obscured.

James Rutka, Toronto, Canada

The authors have reviewed their experience with the use of gamma knife radiosurgery (GKR) in over 308 patients treated for brain metastases at their institution over a time period of 6 years. Thirteen patients, a small percentage of the total, were found to have progressive symptomatology and increasing tumor size despite the use of GKR, and went on to have neurosurgical resection of their lesions. These patients did well, especially since the advent of technologies which have improved neurosurgical outcomes such as image guidance, and were well served by these resections.

The reasons for tumor progression are twofold: one, there is the intrinsic radioresistance of brain metastases which is known for several different cancer subtypes; and two, in patients who have previously undergone whole brain irradiation, or who have received higher dose GKR, radiation necrosis is possible. Despite our best efforts to diagnose which of these two possibilities has occurred, there are no fool proof pre-operative imaging studies or laboratory tests which can unequivocally provide the answer.

It should be stated that the overall survival of these patients who progress after GKR is not improved despite neurosurgical resection of their lesions.

This stands to reason given the heavy systemic tumor burden these patients frequently have. Still, the study is a good reminder of how helpful neurosurgical resection can be, if performed safely and without morbidity, to this particular patient population in need.

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Peev, N.A., Hirose, Y., Hirai, T. et al. Delayed surgical resections of brain metastases after gamma knife radiosurgery. Neurosurg Rev 33, 349–357 (2010). https://doi.org/10.1007/s10143-010-0264-7

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