Abstract
BackgroundStereotactic irradiation (STI) is a primary treatment for patients with newly diagnosed brain metastases. Some of these patients experience local progression, which is difficult to differentiate from radiation necrosis, and difficult to treat. So far, just a few studies have clarified the prognosis and effectiveness of salvage surgery after STI. We evaluated the diagnostic value and improvement of functional outcomes after salvage surgery. Based on these results, we reconsidered surgical indication for patients with local progression after STI.MethodsWe evaluated patients with brain metastases treated with salvage surgery for local progression from October 2002 to July 2019. These patients had undergone salvage surgery based on magnetic resonance imaging findings and/or clinical evidence of post-STI local progression and stable systemic disease. We employed two prospective strategies according to the eloquency of the lesions. Lesions in non-eloquent areas had been resected completely with a safety margin, utilizing a fence-post method; while lesions in eloquent areas had been treated with minimal resection and postoperative STI. Kaplan-Meier curves were used for the assessment of overall survival. Prognostic factors for survival were analyzed.ResultsFifty-four salvage surgeries had been performed on 48 patients. The median age of patients was 63.5 years (range 36–79). The median interval from STI to surgery was 12 months. The median overall survival was 20.2 months from salvage surgery and 37.5 months from initial STI. Primary cancers were lung 31, breast 9, and others 8. Local recurrence developed in 13 of 54 lesions (24%). Leptomeningeal dissemination occurred after surgery in 3 patients (5.6%). Primary breast cancer (breast vs. lung: HR: 0.17), (breast vs. others: HR: 0.08) and RPA class 1–2 (RPA 1 vs. 3, HR:0.13), (RPA 2 vs 3, HR:0.4) were identified as good prognostic factors for overall survival (OS) in multivariate analyses. The peripheral neutrophil-to-lymphocyte ratio (NLR) of ≤3.65 predicted significantly longer OS (median 25.5 months) than an NLR > 3.65 (median 8 months).ConclusionWe insist that salvage surgery leads to rapid improvement of neurological function and clarity of histological diagnosis. Salvage surgery is recommended for large lesions especially with surrounding edema either in eloquent or non-eloquent areas.
Highlights
Stereotactic irradiation (STI) is a primary treatment for patients with newly diagnosed brain metastases
We insist that salvage surgery leads to rapid improvement of neurological function and clarity of histological diagnosis
If this 18-years observation period is divided into halves, salvage surgeries increased in number from 20 cases in the first 9 years, and to 34 cases in the recent 9 years
Summary
Stereotactic irradiation (STI) is a primary treatment for patients with newly diagnosed brain metastases Some of these patients experience local progression, which is difficult to differentiate from radiation necrosis, and difficult to treat. We evaluated the diagnostic value and improvement of functional outcomes after salvage surgery Based on these results, we reconsidered surgical indication for patients with local progression after STI. Stereotactic irradiation (STI) is a primary treatment option in the initial management of patients with brain metastases [1]. With improved local and systemic management in recent years, patients with brain metastases survive for longer periods. These post-STI patients are showing late clinical deterioration with locally progressive mass lesions
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