The expanding role of neurosurgeons in the management of brain metastases

Sheehan, Jason P.; Niranjan, Ajay; Flickinger, John C.; Kondziolka, Douglas; Lunsford, L. Dade

doi:10.1016/j.surneu.2003.10.033

Cited by 45 publications

(22 citation statements)

References 63 publications

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“…The actual incidence may be much higher according to some estimates [3] . Modern reports estimate that intracranial metastases occur in 20-40% of all cancer patients and that metastatic intracranial disease is symptomatic in approximately two thirds of all cases [4] .…”

Section: Introductionmentioning

confidence: 99%

Optimizing Intracranial Metastasis Detection for Stereotactic Radiosurgery

Engh

Flickinger

Niranjan

et al. 2007

Stereotact Funct Neurosurg

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Background and Purpose: The authors characterize the detection of additional intracranial metastases in cancer patients at the time of stereotactic radiosurgery (SRS) using a specialized high-resolution magnetic resonance imaging (MRI) protocol. Methods: A retrospective review of 150 consecutive radiosurgical procedures for patients with ≤5 known metastatic intracranial tumors diagnosed using MRI was undertaken at a single center. On the day of SRS, all patients underwent rigid head fixation in a stereotactic frame followed by a specialized MRI using a 3-dimensional fast spoiled-gradient sequence on a 1.5-tesla magnet with double-dose gadolinium. Axial imaging was performed using 2-mm cuts and no gap. Results: Additional metastases were detected in 29.3% of patients. The number of known tumors before SRS was predictive of additional metastases being found (p = 0.014). In multivariate analysis, we more frequently found additional metastases at radiosurgery in patients with 3–5 previously known metastases (p = 0.005), in patients with non-small cell lung cancer (p = 0.012) and in patients with a longer time interval between their diagnostic MRI and their stereotactic MRI (p = 0.030). Age, sex and prior fractionated radiation therapy were not predictive factors. Conclusion:Our specialized protocol of high-resolution, double-dose contrast-enhanced MRI is a reliable method to evaluate the extent of intracranial disease in patients with known brain metastasis. Treatment planning for radiosurgery, radiation therapy and open surgical therapy are all impacted by improved metastasis detection.

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Section: Introductionmentioning

confidence: 99%

Optimizing Intracranial Metastasis Detection for Stereotactic Radiosurgery

Engh

Flickinger

Niranjan

et al. 2007

Stereotact Funct Neurosurg

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“…In the last few decades, satisfactory radiosurgical outcomes in treating small to moderate-size MBTs have been reported after long-term follow-up. 15 Radiosurgery is used typically to treat brain metastases that are 3 cm or smaller in maximum diameter. Nevertheless, in the RTOG 9508 study, the use of radiosurgery was permitted for one tumor that was up to 4 cm in diameter.…”

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confidence: 99%

Large intracranial metastatic tumors treated by Gamma Knife surgery: outcomes and prognostic factors

Lee

Yen

et al. 2014

JNS

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Object The use of radiosurgery has been well accepted for treating small to medium-size metastatic brain tumors (MBTs). However, its utility in treating large MBTs remains uncertain due to potentially unfavorable effects such as progressive perifocal brain edema and neurological deterioration. In this retrospective study the authors evaluated the local tumor control rate and analyzed possible factors affecting tumor and brain edema response. Methods The authors defined a large brain metastasis as one with a measurement of 3 cm or more in at least one of the 3 cardinal planes (coronal, axial, or sagittal). A consecutive series of 109 patients with 119 large intracranial metastatic lesions were treated with Gamma Knife surgery (GKS) between October 2000 and December 2012; the median tumor volume was 16.8 cm3 (range 6.0–74.8 cm3). The pre-GKS Karnofsky Performance Status (KPS) score for these patients ranged from 70 to 100. The most common tumors of origin were non–small cell lung cancers (29.4% of cases in this series). Thirty-six patients (33.0%) had previously undergone a craniotomy (1–3 times) for tumor resection. Forty-three patients (39.4%) underwent whole-brain radiotherapy (WBRT) before GKS. Patients were treated with GKS and followed clinically and radiographically at 2- to 3-month intervals thereafter. Results The median duration of imaging follow-up after GKS for patients with large MBTs in this series was 6.3 months. In the first follow-up MRI studies (performed within 3 months after GKS), 77 lesions (64.7%) had regressed, 24 (20.2%) were stable, and 18 (15.1%) were found to have grown. Peritumoral brain edema as defined on T2-weighted MRI sequences had decreased in 79 lesions (66.4%), was stable in 21 (17.6%), but had progressed in 19 (16.0%). In the group of patients who survived longer than 6 months (76 patients with 77 MBTs), 88.3% of the MBTs (68 of 77 lesions) had regressed or remained stable at the most recent imaging follow-up, and 89.6% (69 of 77 lesions) showed regression of perifocal brain edema volume or stable condition. The median duration of survival after GKS was 8.3 months for patients with large MBTs. Patients with small cell lung cancer and no previous WBRT had a significantly higher tumor control rate as well as better brain edema relief. Patients with a single metastasis, better KPS scores, and no previous radiosurgery or WBRT were more likely to decrease corticosteroid use after GKS. On the other hand, higher pre-GKS KPS score was the only factor that showed a statistically significant association with longer survival. Conclusions Treating large MBTs using either microsurgery or radiosurgery is a challenge for neurosurgeons. In selected patients with large brain metastases, radiosurgery offered a reasonable local tumor control rate and favorable functional preservation. Exacerbation of underlying edema was rare in this case series. Far more commonly, edema and steroid use were lessened after radiosurgery. Radiosurgery appears to be a reasonable option for some patients with large MBTs.

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“…This is due to the fact that the blood-brain barrier prevents most chemotherapeutic agents from passing to the brain parenchyma. While surgical methods and the administration of excision or radiotherapy may be partially effective in solitary brain metastases, the disease may become fatal in multiple metastatic lesions and/or typically small cell carcinoma and melanoma, and even when there is leptomeningeal involvement associated with breast cancer [61,62].…”

Section: Detection and Importance Of Metastatic Brain Tumorsmentioning

confidence: 99%

Role of Pathologist in Driver of Treatment of CNS Tumors

Altınay¹

2017

New Approaches to the Management of Primary and Secondary CNS Tumors

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The incidence of Central Nervous System (CNS) tumors is gradually increasing. Furthermore, metastatic neoplasms are frequently seen in neuropathology practice as a major cause of mortality and morbidity. Pathologists try to reach a more accurate diagnosis by mentally filtering a synthesis, comprising age, radiological characteristics and microscopic findings in the sample sent, starting already from the intraoperative diagnosis process. By displaying their skills, they unveil whether a lesion in the brain parenchyma is a normal or reactive tumor and if this is a tumor, is it primary or metastatic, and if it is primary, what is the tumor type or if it is metastatic, which organ could it be associated with. Pathologists use diagnostic, prognostic and predictive markers in order to enable the patient receive the most effective and sufficient treatment. They ensure that an individualized treatment is provided via these tools, by making a histological diagnosis of the lesion according to the WHO classification, identifying the course of the disease and preventing undesired and dangerous complications. This chapter will focus on answering these questions and share the value of a multidisciplinary approach in the management of brain tumors in neurosciences, which is gradually increasing in importance, and how pathologists execute this art.

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The expanding role of neurosurgeons in the management of brain metastases

Cited by 45 publications

References 63 publications

Optimizing Intracranial Metastasis Detection for Stereotactic Radiosurgery

Optimizing Intracranial Metastasis Detection for Stereotactic Radiosurgery

Large intracranial metastatic tumors treated by Gamma Knife surgery: outcomes and prognostic factors

Role of Pathologist in Driver of Treatment of CNS Tumors

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