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Incidence of local in-brain progression after supramarginal resection of cerebral metastases

  • Clinical Article - Brain Tumors
  • Published:
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Abstract

Background

Microsurgical circumferential stripping of intracerebral metastases is often insufficient in achieving local tumor control. Supramarginal resection may improve local tumor control.

Methods

A retrospective analysis was performed for patients who underwent supramarginal resection of a cerebral metastasis by awake surgery with intraoperative cortical and subcortical stimulation, MEPs, and SSEPs. Supramarginal resection was achieved by circumferential stripping of the metastasis and additional removal of approximately 3 mm of the surrounding tissue. Pre- and postsurgical neurological status was assessed by the NIH Stroke Scale. Permanent deficits were defined by persistence after 3-month observation time.

Results

Supramarginal resection of cerebral metastases in eloquent brain areas was performed in 34 patients with a mean age of 60 years (range, 33–83 years). Five out of 34 patients (14.7 %) had a new transient postoperative neurological deficit, which improved within a few days due to supplementary motor area (SMA) syndrome. Five out of 34 patients (14.7 %) developed a local in-brain progression and nine patients (26.4 %) a distant in-brain progression.

Conclusions

Supramarginal resection of cerebral metastases in eloquent locations is feasible and safe. Safety might be increased by intraoperative neuromonitoring. The better outcome in the present series may be entirely based on other predictors than extend of surgical resection and not necessarily on the surgical technique applied. However, supramarginal resection was safe and apparently did not lead to worse results than regular surgical techniques. Prospective, controlled, and randomized studies are mandatory to determine the possible benefit of supramarginal resection on local tumor control and overall outcome.

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Conflict of interest

None.

Funding

The present study was not funded.

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Author notes

    Authors and Affiliations

    1. Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany

      Marcel A. Kamp, Marion Rapp, Philipp J. Slotty, Hosai Sadat, Maria Smuga, Maxine Dibué-Adjei, Hans-Jakob Steiger, Andrea Szelényi & Michael Sabel

    2. Institute for Diagnostic and Interventional Radiology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany

      Bernd Turowski

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    1. Marcel A. Kamp
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    2. Marion Rapp
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    3. Philipp J. Slotty
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    5. Hosai Sadat
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    6. Maria Smuga
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    9. Andrea Szelényi
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    10. Michael Sabel
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    Correspondence to Marcel A. Kamp.

    Additional information

    Comment

    This is a single-center, retrospective study of 34 patients who underwent MRI-verified supramarginal resection of a single cerebral metastasis in an eloquent area by awake surgery with intraoperative monitoring. The study demonstrates that supramarginal resection was feasible as no permanent postoperative neurological deficits were observed. Furthermore, supramarginal resection achieved better tumor control.

    The strengths of this study, albeit a retrospective one, are the clear definitions of eloquence, inclusion criteria and exclusion criteria, the very careful follow-up with outpatient clinic and MRI every 3 months, and that the limitations of the study are identified and clearly stated. Furthermore, the analysis is careful and the discussion is precise and pertinent. The results are not “over-sold”, although the supramarginal resection resulted in a very low local in-brain progression.

    There are some weaknesses, such as the retrospective design and that proof of concept has been previously demonstrated for metastases in non-eloquent areas. The study group is selected. Six patients (15 %) were excluded from the study as the intraoperative monitoring suggested further resection would result in neurological deficits. Furthermore, due to the strict inclusion and exclusion criteria, a number of patients with metastases in eloquent regions must have been excluded. We are not given information about them. Lastly, although the neurological outcome was scored using standardized methods, it was not scored by an independent operator.

    There are also some unanswered questions. One inclusion criterion is a complete set of pre- and postoperative MRI. How many were excluded due to lack of postoperative MRI? There is clearly a selection bias unless every single patient has a postoperative MRI and not at the surgeon’s discretion. Surgeon-independent confirmation of a supramarginal resection was not performed, nor quantification of supramarginal resection beyond tumor resection. What substantiates the notion that supramarginal resection is different from your standard MRI-verified complete extirpation?

    Torstein Meling

    Oslo, Norway

    Marcel A. Kamp and Marion Rapp contributed equally to this work.

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    Kamp, M.A., Rapp, M., Slotty, P.J. et al. Incidence of local in-brain progression after supramarginal resection of cerebral metastases. Acta Neurochir 157, 905–911 (2015). https://doi.org/10.1007/s00701-015-2405-9

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    • DOI: https://doi.org/10.1007/s00701-015-2405-9

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