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. 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%. 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.
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%.
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.
Evidence summary and recommendations
|Local control rates after surgical resection of melanoma brain metastases are very high, in the order of 80–93%||I, III-2||, , , , |
|Surgery is highly effective in relieving symptoms and improving functional outcome.||I, III-2||, , , |
|Perioperative surgical mortality is approximately 2% whilst complications occur in 6–8% of patients.||III-2||, |
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.
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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