Abstract
IntroductionBrain metastases are the most common brain tumors in adults, whose management remains nuanced. Improved understanding of risk factors for surgical complications and mortality may guide treatment decisions.MethodsA nationwide, multicenter analysis was conducted with a retrospective cohort. Adult patients in the 2012-2015 American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) databases who received a craniotomy for resection of brain metastasis were included.Results3500 cases were analyzed, of which 17% were considered frail and 24% were infratentorial. The most common 30-day medical complications were venous thromboembolism (3%, median time-to-event [TTE] 4.5 days), pneumonia (4%, median TTE 6 days), and urinary tract infections (2%, median TTE 5 days). Reoperation and unplanned readmission occurred in 5% and 12% of patients, respectively. Infratentorial approach and frailty were associated with reoperation before discharge (OR 2.0 for both; p=0.01 and p=0.03 respectively), but not after discharge. Infratentorial approaches conferred heightened risk for readmission for hydrocephalus (OR 5.1, p=0.02) and reoperation for cerebrospinal fluid diversion (OR 7.1, p<0.001).Overall 30-day mortality was 4%, with nearly three-quarters occurring after discharge. Pre-frailty and frailty were associated with increased odds for post-discharge mortality (OR 1.7 and 2.7, p<0.05), but not pre-discharge mortality. We developed a model to identify pre-/peri-operative variables associated with death, including frailty, thrombocytopenia, and high American Society of Anesthesiologists score (AUROC 0.75).ConclusionsOptimization of metrics contributing to patient frailty and heightened surveillance in patients with infratentorial metastases may be considered in the peri-operative period.
Highlights
Brain metastases are the most common brain tumors in adults, whose management remains nuanced
Reoperation and unplanned readmission occurred in 5% and 12% of patients, respectively
Infratentorial approaches conferred heightened risk for readmission for hydrocephalus and reoperation for cerebrospinal fluid diversion.Overall 30-day mortality was 4%, with nearly three-quarters occurring after discharge
Summary
Brain metastases are the most common brain tumors in adults, whose management remains nuanced. Improved understanding of risk factors for surgical complications and mortality may guide treatment decisions. The overall annual incidence of brain metastasis amongst cancer patients ranges from 2-10% and varies greatly by primary cancer origin, tumor stage, and demographic factors including race and age [1,2,3]. The incidence of brain metastasis has increased over the past 20 years in parallel with improved metastasis detection and treatment of the primary cancer; as patients live longer, their risk of brain metastasis increases [4, 5]. Among patients with brain metastases, median survival ranges from 3 months for pancreatic cancer, to 6-9 months for melanoma, to 6-13 months or longer for lung and breast cancer [6,7,8,9]. For patients with finite life expectancy from their malignancy, the expected benefits should outweigh the potential risks to optimize quality of life
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