Palliative Resection of Metastatic Brain Tumors Previously Treated by Stereotactic Radiosurgery

Abstract

BackgroundTherapeutic approaches to brain metastases include surgery, whole-brain radiotherapy, stereotactic radiosurgery (SRS), and combination therapy. Recently, postoperative or preoperative SRS draws more attention to reduce postoperative recurrence in brain metastases. The goal of this study is to review surgical outcome of patients who had been treated by SRS, and to discuss the effectiveness of preoperative SRS.MethodsFrom 2009 to 2015, 174 patients were treated by SRS for brain metastases, and among these 50 patients underwent surgery. Eighteen patients underwent surgery after SRS, and 14 had oligometastases. The patients' median age at the time of surgery was 56 years (range, 34–84 years). The median follow-up duration was 16.5 months (range, 4–47 months). Pathological findings were classified as follows; radiation necrosis (Group I, n=3), mixed type (Group II, n=2), and tumor-dominant group (Group III, n=9). We compared surgical outcome in respect of steroid, mannitol dosage, Karnofsky performance scale, and pathological subgroups.ResultsThe median overall survival was 11 months (range, 2–40 months). Six, 12 and 24 months survival rate was 64.3, 42.9, and 28.6%, respectively. Improvement of Karnofsky performance score was achieved in 50% after surgery. The overall survival of Group I (26.6 months) was longer than the other groups (11.5 months). Additionally the patients were able to be weaned from medications, such as steroid administration after surgery was reduced in 10 cases, and mannitol dosage was reduced in 6 cases. Time interval within 3 months between SRS and surgery seemed to be related with better local control.ConclusionSurgical resection after radiologically and symptomatically progressed brain metastases previously treated with SRS seems to be effective in rapid symptom relief and provides an improvement in the quality of life. A short time interval between SRS and surgical resection seems to be associated with good local tumor control.

Operative and peri‐operative considerations in the management of brain metastasis

“…In patients who underwent resection within three months after SRS, there was no local recurrence, suggesting that neoadjuvant SRS is feasible in certain patients. However, due to the limited sample size, investigators were unable to detect a difference in survival if surgery was offered within this time frame . Given the retrospective nature of this study and the observed benefit in subsets of these patients, further investigation in this area is warranted.…”

Modern Ideas About the Combination of Radiation Therapy With Antiangiogenic Drugs in the Treatment of Patients With Brain Metastases

“…Риск кровотечения из ЦНС был основной проблемой при введении антиангиогенной терапии в практику и приводил к частому исключению пациентов с метастазами головного мозга из клинических исследований [16]. Однако в ряде последующих исследований было доказано, что проблема повышенной опасности отсутствует, так как частота кровотечений, а также других побочных эффектов у пациентов с метастазами в головном мозге не увеличивалась [16][17][18][19][20][21][22][23][24][25][26][27][28]. В соответствии с этим частота побочных явлений, связанных с бевацизумабом, была одинаковой у пациентов с (21 %) и без (20 %) метастазов в головной мозг [17].…”

“…При рецидиве метастатического поражения головного мозга возможно нейрохирургическое вмешательство для облегчения симптомов, вызванных масс-эффектом опухоли и перитуморальным отеком. Кроме того, повторное облучение также может быть тщательно рассмотрено как вариант повторной терапии при ранее облученных поражениях [25]. Однако лучевой некроз является потенциальным осложнением и связан со значительной неврологической симптоматикой вследствие масс-эффекта большого перитуморального отека.…”

Anti-angiogenic therapies in brain metastases

“…Upon recurrence, neurosurgical resection can be considered as a salvage therapy if immediate symptom relief due to mass effect of the surrounding peritumoral edema is needed. Further, re-radiation can also be considered carefully in previously radiated lesions [ 22 ]. However, radiation necrosis is a potential complication and associated with significant neurological morbidity due to the mass effect of the large peritumoral edema.…”