Salvage Surgery for Local Control of Brain Metastases After Previous Stereotactic Radiosurgery: A Single-Center Series

Daniel D Cummins; Ramin A Morshed; Miguel M Chavez; Lauro N Avalos; Vivek Sudhakar; Jason E Chung; Aaron Gallagher; Satvir Saggi; Mariza Daras; Steve Braunstein; Philip V Theodosopoulos; Michael W McDermott; Manish K Aghi

doi:10.1016/j.wneu.2021.10.179

Salvage Surgery for Local Control of Brain Metastases After Previous Stereotactic Radiosurgery: A Single-Center Series

World Neurosurg. 2022 Feb:158:e323-e333. doi: 10.1016/j.wneu.2021.10.179. Epub 2021 Nov 2.

Authors

Affiliations

¹ Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA; School of Medicine, University of California, San Francisco, San Francisco, California, USA.
² Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA. Electronic address: ramin.morshed@ucsf.edu.
³ School of Medicine, University of California, San Francisco, San Francisco, California, USA.
⁴ School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
⁵ Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
⁶ Department of Radiation Oncology, University of California, San Francisco, San Francisco, California, USA.
⁷ Division of Neurosurgery, Miami Neuroscience Institute, Miami, Florida, USA.

PMID: 34740830
DOI: 10.1016/j.wneu.2021.10.179

Abstract

Background: Although overall survival (OS) has improved in patients with brain metastases (BMs), control of recurrent BMs remains a therapeutic challenge. Salvage surgery may achieve acceptable control rates in the setting of progression after previous stereotactic radiosurgery (SRS), yet it remains a question how additional adjuvant therapies may affect outcomes and how patient selection for salvage surgery may be optimized.

Methods: Patients receiving salvage surgery for BM progression after previous SRS were retrospectively reviewed from a single center. Outcomes of interest included local tumor progression, leptomeningeal dissemination, and OS. Cox proportional hazard models and nominal logistic regression were applied to determine factors associated with outcomes of interest.

Results: A total of 43 patients with 50 BMs were included. After salvage surgery, local progression was observed for 17 BMs (34%), leptomeningeal dissemination was observed in 17 patients (39.5%), and censored median OS was 17.9 months. On multivariate analysis, use of brachytherapy was associated with improved local control (hazard ratio [HR], 0.15; 95% confidence interval [CI], 0.04-0.6; P = 0.008). For patients treated with SRS ≥4.5 months before salvage surgery, both brachytherapy (HR, 0.07; 95% CI, 0.01-0.39; P = 0.002) and postoperative adjuvant SRS (HR, 0.14; 95% CI, 0.02-1.00; P = 0.05) were associated with improved local control compared with no adjuvant radiation therapy. Presence of extracranial malignancy (HR, 6.70; 95% CI, 2.58-17.42; P < 0.0001) was associated with shorter survival. Graded prognostic assessment underestimated survival in 79.1% of patients, with a mean difference of 18.9 months between graded prognostic assessment-estimated and actual OS.

Conclusions: In properly selected patients, salvage surgery may be an appropriate therapy for BM progression after previous SRS. Adjuvant brachytherapy and repeat SRS can offer significant benefit for local control with salvage resection.

Keywords: Brachytherapy; Brain metastasis; Leptomeningeal disease; Local control; Radiosurgery; Salvage surgery.

MeSH terms

Brain Neoplasms* / radiotherapy
Brain Neoplasms* / secondary
Brain Neoplasms* / surgery
Humans
Radiosurgery* / adverse effects
Retrospective Studies
Salvage Therapy
Treatment Outcome