Recommended surgical approach to brain metastases in patients with advanced melanoma

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Evidence

What is the recommended surgical approach to brain metastases in patients with advanced melanoma?

Safe resection of brain metastases relates largely to their location within the brain. The vast majority of brain metastases occur in locations where the risk of new or worsening neurological deficit following surgery is low. However certain deep parts of the brain and brainstem remain inoperable areas. Apart from acute, life-threatening presentations, all other cases of melanoma brain metastases should ideally be discussed by a multidisciplinary team prior to embarking on treatment.

In 1990, Patchell et al conducted a randomised trial assessing surgery and whole brain radiotherapy versus whole brain radiotherapy alone for single brain metastasis.[1] The cohort consisted of 48 patients with different histologies (three patients with melanoma). They showed that the surgical resection group had significantly fewer local recurrences and significantly higher overall survival (40 weeks vs 15 weeks, p<0.01). The surgical group also remained functionally independent for longer (38 weeks vs 8 weeks, p<0.005). The authors of this landmark paper demonstrated that surgery is a valuable treatment modality for brain metastases of all histological subtypes. Since then, studies relating to surgical resection of brain metastases have been limited largely to retrospective cohorts, especially in the case of melanoma.

Local control rates after surgical resection in more contemporary surgical series have been in the order of 80–93%.[1][2][3][4][5] These studies advocate an en bloc resection technique, with mandatory use of neuro navigation. However, most patients in contemporary series were subject to multimodal treatment that undoubtedly contributed to the low recurrence rates.

Overall survival (OS) from the time of diagnosis of brain metastases has been steadily rising. In the current decade, patients who have had surgical resection of one or more lesions have a median OS of 13–16 months.[4]

Surgical morbidity and perioperative mortality have steadily declined over the last couple of decades. Perioperative mortality is currently approximately 2%, whilst the surgical complication rate is approximately 6–8%.[6]

In current clinical practice, new questions are emerging that are yet to be addressed. These include the optimal management of more complex patients who present with multiple brain metastases and/or leptomeningeal disease and determining the interaction of different modalities of treatment.

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Evidence summary and recommendations

Evidence summary Level References
Local control rates after surgical resection of melanoma brain metastases are very high, in the order of 80–93% I, III-2 [1], [2], [3], [4], [5]
Surgery is highly effective in relieving symptoms and improving functional outcome. I, III-2 [1], [7], [8], [9]
Perioperative surgical mortality is approximately 2% whilst complications occur in 6–8% of patients. III-2 [6], [8]


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Brain metastases that are symptomatic or generate mass effect at presentation are best treated with surgery, which results in rapid relief of symptoms and maintenance of functional independence.


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Surgical resection of brain metastases provides safe, durable local disease control. The use of the operating microscope, neuro navigation and an en bloc resection technique are recommended. The integration of surgery with systemic therapy and radiotherapy should be discussed by a multidisciplinary team.


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References

  1. 1.0 1.1 1.2 1.3 Patchell RA, Tibbs PA, Walsh JW, Dempsey RJ, Maruyama Y, Kryscio RJ, et al. A randomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med 1990 Feb 22;322(8):494-500 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/2405271.
  2. 2.0 2.1 Salvati M, Frati A, D'Elia A, Pescatori L, Piccirilli M, Pietrantonio A, et al. Single brain metastases from melanoma: remarks on a series of 84 patients. Neurosurg Rev 2012 Apr;35(2):211-7; discussion 217-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21915621.
  3. 3.0 3.1 Lonser RR, Song DK, Klapper J, Hagan M, Auh S, Kerr PB, et al. Surgical management of melanoma brain metastases in patients treated with immunotherapy. J Neurosurg 2011 Jul;115(1):30-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21476810.
  4. 4.0 4.1 4.2 Miller D, Zappala V, El Hindy N, Livingstone E, Schadendorf D, Sure U, et al. Intracerebral metastases of malignant melanoma and their recurrences--a clinical analysis. Clin Neurol Neurosurg 2013 Sep;115(9):1721-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23643143.
  5. 5.0 5.1 Carrubba CJ, Vitaz TW. Factors affecting the outcome after treatment for metastatic melanoma to the brain. Surg Neurol 2009 Dec;72(6):707-11 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19604550.
  6. 6.0 6.1 Zacest AC, Besser M, Stevens G, Thompson JF, McCarthy WH, Culjak G. Surgical management of cerebral metastases from melanoma: outcome in 147 patients treated at a single institution over two decades. J Neurosurg 2002 Mar;96(3):552-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11883841.
  7. Fife KM, Colman MH, Stevens GN, Firth IC, Moon D, Shannon KF, et al. Determinants of outcome in melanoma patients with cerebral metastases. J Clin Oncol 2004 Apr 1;22(7):1293-300 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15051777.
  8. 8.0 8.1 Paek SH, Audu PB, Sperling MR, Cho J, Andrews DW. Reevaluation of surgery for the treatment of brain metastases: review of 208 patients with single or multiple brain metastases treated at one institution with modern neurosurgical techniques. Neurosurgery 2005 May;56(5):1021-34; discussion 1021-34 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15854250.
  9. Schödel P, Schebesch KM, Brawanski A, Proescholdt MA. Surgical resection of brain metastases-impact on neurological outcome. Int J Mol Sci 2013 Apr 24;14(5):8708-18 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23615466.

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