The role of surgery for brain metastases from solid tumors

Anamnestic radiological metastases outcome surgical score (ARMO-S). A purpose of a predictive surgical scoring system for brain metastases

BACKGROUND

Several risk stratification scores have been suggested to aid prognostication and guide treatment strategies for brain metastases (BMs). However, the current scores do not focus on the specific neurosurgical population, therefore not predicting short-term mortality and postoperative performance status.

METHODS

This retrospective observational study of 362 consecutive patients treated with surgery for BMs aims to identify the factors associated with post-surgical outcomes and propose a surgery-specific prognostic score for patients with BMs candidate for open surgery.

RESULTS

Factors significantly associated with OS and performance status in multivariate analysis were age, KPS, surgical site, synchronous debut of BM, number, tumor volume, seizure, extra-cranial metastases, and deep-seated location. The variables were incorporated into the Anamnestic Radiological Metastases Outcome Surgical score (ARMO-S). The values range between 0 and 10. Patients were divided into two groups (low-risk and high-risk) based on each significant subgroup's median survival and performance status with an optimal cutoff value determined as 4. The two groups have significant differences in OS (9.6 versus 14 months, p = 0.0048) postoperative KPS (90 versus 70, p = 0.012) and KPS at last follow-up evaluation (75 versus 30, p < 0.001) CONCLUSION: ARMO-S is a simple and comprehensive score for BM patients selected for neurosurgery, as it incorporates the main factors of the most important prognostic scores, implementing them with more surgery-specific predictive elements such as tumor location and volume, presence of seizures at onset, and involvement of eloquent brain areas.

Preoperative Prognostic Index for Patients with Brain Metastases-A Population-Based Multi-Centre Study

BACKGROUND

Brain metastases (BM) are common in cancer patients and are associated with high morbidity and mortality. Surgery is an option, but the optimal selection of patients for surgery is challenging and controversial. Current prognostication tools are not ideal for preoperative prognostication. By using a reference population (derivation data set) and two external populations (validation data set) of patients who underwent surgery for BM, we aimed to create and validate a preoperative prognostic index.

METHODS

The derivation data set consists of 590 patients who underwent surgery for BM (2011-2018) at Oslo University Hospital. We identified variables associated with survival and created a preoperative prognostic index with four prognostic groups, which was validated on patients who underwent surgery for BM at Karolinska University Hospital and St. Olavs University Hospital during the same time period. To reduce over-fitting, we adjusted the index in accordance with our findings.

RESULTS

438 patients were included in the validation data set. The preoperative prognostic index correctly divided patients into four true prognostic groups. The two prognostic groups with the poorest survival outcomes overlapped, and these were merged to create the adjusted preoperative prognostic index.

CONCLUSION

We created a prognostic index for patients with BM that predicts overall survival preoperatively. This index might be valuable in supporting informed choice when considering surgery for BM.

Recurrence benefit from supramarginal resection in brain metastases of lung adenocarcinoma

Background

There is growing evidence that brain metastases (BM) have no well-defined boundaries and that conventional microsurgical circumferential dissection of BM is often inadequate to prevent local tumor recurrence. Previous studies have suggested that supramarginal resection can significantly improve local tumor control. We retrospectively analyzed the local tumor control in a series of patients with BM from lung adenocarcinoma.

Methods

We retrospectively analyzed 48 patients with BM for lung adenocarcinoma in Shenzhen Second People’s Hospital from May 2015 to May 2020. 26 resected lesions were located in eloquent areas and underwent standard gross total resection (GTR group); 22 resected lesions were located in ineloquent areas, after standard gross total resection, the periphery was expanded and resected by 5 mm (MTR group). The postoperative tumor recurrence was compared between the two groups.

Results

During the follow-up period, the local recurrence rates in the GTR group and the MTR group were 61.5% and 27.3% (p = 0.022), respectively. Within 6 months after surgery, the local recurrence rates in the GTR group and the MTR group were 42.3% and 13.6% (p = 0.029), respectively. Within 12 months after surgery, the local recurrence rates in the GTR group and the MTR group were 57.7% and 22.7% (p = 0.014), respectively. The median progression-free survival time after surgery was 7.0 months (95% CI 4.0–10.0 months) in the GTR group and 14.0 months (95% CI 11.4–16.6 months) in the MTR group (Log-Rank p = 0.008). Compared with the MTR group, the HR of local recurrence in the GTR group was 3.74 (95% CI 1.38–10.39, p = 0.010). Cox multivariable analysis showed no other factors associated with local recurrence except for the surgical method (p = 0.012).

Conclusions

On the basis of conventional surgical total resection, expanded peripheral resection of 5 mm around the brain metastases of lung adenocarcinoma can significantly reduce the local recurrence rate and prolongs the progression-free survival time.

Surgical Management of Brain Metastases in the Perirolandic Region

Brain metastases (BM) are the most frequent intracranial tumors, which may result in significant morbidity and mortality when the lesions involve the perirolandic region. Surgical intervention for BM in the perirolandic region is still under discussion even though prompt relief of mass effect and avoidance of necrosis together with brain edema may not be achieved by radiotherapy. More recently, several researchers attempt to evaluate the benefit of surgery for BM within this pivotal sensorimotor area. Nevertheless, data are sparse and optimal treatment paradigm is not yet widely described. Since the advance in intraoperative neuroimaging and neurophysiology, resection of BM in the perirolandic region has been proven to be safe and efficacious, sparing this eloquent area while retaining reasonably low morbidity rates. Although management of BM becomes much more tailored and multimodal, surgery remains the cornerstone and principles of resection as well as indications for surgery should be well defined. This is the first review concerning the characteristics of BM involving the perirolandic region and the current impact of surgical therapy for the lesions. Future perspectives of advanced neurosurgical techniques are also presented.

The Role of Stereotactic Radiosurgery in the Management of Brain Metastases From a Health-Economic Perspective: A Systematic Review

BACKGROUND

Stereotactic radiosurgery (SRS) is an effective option in the management of brain metastases, offering improved overall survival to whole-brain radiation therapy (WBRT). However, given the need for active surveillance and the possibility of repeated interventions for local/distant brain recurrences, the balance between clinical benefit and economic impact must be evaluated.

OBJECTIVE

To conduct a systematic review of health-economic analyses of SRS for brain metastases, compared with other existing intervention options, to determine the cost-effectiveness of this treatment across different clinical scenarios.

METHODS

The MEDLINE, EMBASE, Cochrane, CRD, and EconLit databases were searched for health-economic analyses, according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, using terms relevant to brain metastases and radiation-based therapies. Simple cost analysis studies were excluded. Quality analysis was based on BMJ Consolidated Health Economics Reporting Standards (CHEERS) checklist.

RESULTS

Eleven eligible studies were identified. For lesions with limited mass effect, SRS was more cost-effective than surgical resection (6 studies). In patients with Karnofsky performance scale (KPS) >70 and good predicted survival, SRS was cost-effective compared to WBRT (7 studies); WBRT became cost-effective with poor performance status or low anticipated life span. Following SRS, routine magnetic resonance imaging surveillance saved $1326/patient compared to symptomatic imaging due to reduced surgical salvage and hospital stay (1 study).

CONCLUSION

Based on our findings, SRS is cost-effective in the management of brain metastases, particularly in high-functioning patients with longer expected survival. However, before an optimal care pathway can be proposed, emerging factors such as tumor molecular subtype, diagnosis-specific graded prognostic assessment, neuroprognostic score, tailored surveillance imaging, and patient utilities need to be studied in greater detail.

PET imaging in patients with brain metastasis-report of the RANO/PET group

Brain metastases (BM) from extracranial cancer are associated with significant morbidity and mortality. Effective local treatment options are stereotactic radiotherapy, including radiosurgery or fractionated external beam radiotherapy, and surgical resection. The use of systemic treatment for intracranial disease control also is improving. BM diagnosis, treatment planning, and follow-up is most often based on contrast-enhanced magnetic resonance imaging (MRI). However, anatomic imaging modalities including standard MRI have limitations in accurately characterizing posttherapeutic reactive changes and treatment response. Molecular imaging techniques such as positron emission tomography (PET) characterize specific metabolic and cellular features of metastases, potentially providing clinically relevant information supplementing anatomic MRI. Here, the Response Assessment in Neuro-Oncology working group provides recommendations for the use of PET imaging in the clinical management of patients with BM based on evidence from studies validated by histology and/or clinical outcome.

Distribution Of Brain Metastasis From Lung Cancer

Purpose

The prognosis of lung cancer with brain metastasis is poor. The purpose of this study was to investigate the distribution of brain metastasis and explore its relationship with pathology and genetic mutations.

Patients and methods

Between June 2015 and July 2018, 335 patients from Shandong Provincial Hospital affiliated to Shandong University who had been firstly diagnosed with brain metastasis from lung cancer were retrospectively reviewed. All metastatic lesions were detected in the corresponding area using magnetic resonance imaging (MRI).

Results

A total of 2046 metastatic lesions were found. Of the 335 patients, 21.2% (71/335) had a single brain metastasis and 78.8% (264/335) had multiple lesions. The cerebellum (56%; 189/335), right parietal lobe (54%; 182/335), right frontal lobe (47%; 157/335), and left frontal lobe (45%; 152/335) were the regions with the highest incidence of brain metastasis. The different pathological types of lung cancer showed different distribution of brain metastasis. In lung adenocarcinoma, the left frontal lobe (53%; 111/208), right frontal lobe (48%; 100/208) and cerebellum (56%; 116/208) exhibited higher brain metastases, while the cerebellum (61%; 45/74) and the right frontal lobe (46%; 34/74) had the highest incidence of brain metastasis from small-cell carcinoma. For lung squamous cell carcinoma, the cerebellum (70%; 14/20) was the most common site for metastasis. Adenocarcinoma was the most common pathological type in patients regardless of the number of lesions (ie, single or multiple brain metastases). Comparison of 37 cases with epidermal growth factor receptor (EGFR) gene mutation versus 26 cases without mutations showed that there was no correlation between the distribution of brain metastasis and gene mutation.

Conclusion

The different pathological types of lung cancer demonstrate different distribution of brain metastasis. These findings may have significant implications in the diagnosis and treatment of brain metastasis from lung cancer.

Current status of PET imaging in neuro-oncology

Over the past decades, a variety of PET tracers have been used for the evaluation of patients with brain tumors. For clinical routine, the most important clinical indications for PET imaging in patients with brain tumors are the identification of neoplastic tissue including the delineation of tumor extent for the further diagnostic and therapeutic management (ie, biopsy, resection, or radiotherapy planning), the assessment of response to a certain anticancer therapy including its (predictive) effect on the patients’ outcome and the differentiation of treatment-related changes (eg, pseudoprogression and radiation necrosis) from tumor progression at follow-up. To serve medical professionals of all disciplines involved in the diagnosis and care of patients with brain tumors, this review summarizes the value of PET imaging for the latter-mentioned 3 clinically relevant indications in patients with glioma, meningioma, and brain metastases.

Management of Intracranial Metastatic Disease With Laser Interstitial Thermal Therapy

Treatment approaches for metastatic brain tumors continue to evolve, with increasing recent emphasis on focal therapies whenever possible. MRI-guided Laser Interstitial Thermal Therapy (LITT) is a minimally invasive surgical option that has broadened the capability of the neurosurgeon in treating difficult-to-treat intracranial lesions. This technology uses image-guided delivery of laser to the target lesion to generate heat and thereby ablate pathological tissue and has expanded the neurosurgical armamentarium for surgical treatment of brain metastases. In this study, we describe the indications for LITT in the management of intracranial metastatic disease and report our institutional experience with LITT.