J Korean Neurosurg Soc.  2017 Nov;60(6):667-675. 10.3340/jkns.2017.0404.002.

Resection and Observation for Brain Metastasis without Prompt Postoperative Radiation Therapy

• Song TW
• Kim IY
• Jung S
• Jung TY
• Moon KS
• Jang WY

• KMID: 2395786
• DOI: http://doi.org/10.3340/jkns.2017.0404.002

Abstract

OBJECTIVE
Total resection without consecutive postoperative whole brain radiation therapy is indicated for patients with a single or two sites of brain metastasis, with close follow-up by serial magnetic resonance imaging (MRI). In this study, we explored the effectiveness, usefulness, and safety of this follow-up regimen.
METHODS
From January 2006 to December 2015, a total of 109 patients (76 males, 33 females) underwent tumor resection as the first treatment for brain metastases (97 patients with single metastases, 12 with two metastases). The mean age was 59.8 years (range 27-80). The location of the 121 tumors in the 109 patients was supratentorial (n=98) and in the cerebellum (n=23). The origin of the primary cancers was lung (n=45), breast (n=17), gastrointestinal tract (n=18), hepatobiliary system (n=8), kidney (n=7), others (n=11), and unknown origin (n=3). The 121 tumors were totally resected. Follow-up involved regular clinical and MRI assessments. Recurrence-free survival (RFS) and overall survival (OS) after tumor resection were analyzed by Kaplan-Meier methods based on clinical prognostic factors.
RESULTS
During the follow-up, MRI scans were done for 85 patients (78%) with 97 tumors. Fifty-six of the 97 tumors showed no recurrence without adjuvant local treatment, representing a numerical tumor recurrence-free rate of 57.7%. Mean and median RFS was 13.6 and 5.3 months, respectively. Kaplan-Meier analysis revealed the cerebellar location of the tumor as the only statistically significant prognostic factor related to RFS (p=0.020). Mean and median OS was 15.2 and 8.1 months, respectively. There were no significant prognostic factors related to OS. The survival rate at one year was 8.2% (9 of 109).
CONCLUSION
With close and regular clinical and image follow-up, initial postoperative observation without prompt postoperative radiation therapy can be applied in patients of brain metastasi(e)s when both the tumor(s) are completely resected.

Keyword

Brain; Metastasis; Gamma knife radiosurgery; Radiotherapy; Stereotactic radiosurgery; Surgery

MeSH Terms

Brain*
Breast
Cerebellum
Follow-Up Studies
Gastrointestinal Tract
Humans
Kaplan-Meier Estimate
Kidney
Lung
Magnetic Resonance Imaging
Male
Neoplasm Metastasis*
Radiosurgery
Radiotherapy
Recurrence
Survival Rate

Figure

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  Fig. 1 Kaplan-Meier curve of mean recurrence-free survival (RFS) for the 97 resected tumors of 85 patients.

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  Fig. 2 Kaplan-Meier analysis for prognostic factors related to recurrence-free survival (RFS). A: Tumor location. B: Time of metastasis. C: Surgical method. D: Origin cancer.

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  Fig. 3 Kaplan-Meier curve of mean overall survival (OS) after tumor resection for 107 patients.

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  Fig. 4 Kaplan-Meier analysis for prognostic factors related to overall survival. A: Age. B: Origin cancer. C: Time of metastasis. D: Surgical method. E: Tumor location. E: Number of metastasis.

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  Fig. 5 Illustrative case 1. A 58-year-old male patient with nonsmall cell lung cancer, who underwent tumor resection and planned observation. Preoperative Gadolinium-enhanced magnetic resonance imaging (MRI) shows an enhanced mass in the left parietal lobe (A). Postoperative 3 months follow-up MRI (B) shows a post-resection cavity without local recurrence, and both 1-year (C) and 4-year follow-up (D) MRIs show no local recurrence.

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  Fig. 6 Illustrative case 2. A 62-year-old female patient with breast cancer, who underwent tumor resection for two tumors and planned observation with regular magnetic resonance imaging (MRI) follow-up. Preoperative Gadolinium-enhanced MRI shows well-enhanced two mass lesions in bilateral frontal lobes (A). Postoperative 3-month follow-up MRI shows post-resection cavities without local recurrence (B). However, both local recurrences and new metastasis (arrow) are observed 6 months after the tumor resection. The patient underwent stereotactic radiosurgery (SRS) for these 3 lesions (C and D). Six months after the SRS, those three lesions were controlled, but, new metastases were observed (E–H), and the patients underwent whole brain radiation therapy (WBRT). Three months after the WBRT, the metastases were all controlled (I–L).

Reference

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