brain metastases the role of surgery dr orazio arena direttore u.o. neurochirurgia ospedale...
TRANSCRIPT
![Page 1: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/1.jpg)
Brain Metastases The Role of Surgery
Dr Orazio ArenaDirettore U.O. Neurochirurgia
Ospedale A.ManzoniLecco
![Page 2: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/2.jpg)
Brain Metastases
• Are the most common brain tumors seen clinically; 10 times more common than primary brain tumors
• Annual Incidence of metastatic tumors:• 4-11 new cases /100 000 / year.
• 9/10 are intracranial metastases and 1/10 are intra-spinal metastases
• Autopsy studies have revealed the presence of intracranial metastases in 24% and intraspinal metastases in 5% of cancer patients
Voohies RM 1980, Fogelholm R 1984, Patchell RA 1985, Shaffrey ME 2004, Brem SN 2009, Mongan JP 2009.
![Page 3: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/3.jpg)
Brain metastases
Primary Tumor site % of brain mets
Lung 50%
Breast 15%
Skin (Melanoma) 10.5%
Unknown primary site 11%
Delattre JY 1988, Posner JB 1995, Silverberg SG 1992, Norden AD 2005,Brem SN 2009
![Page 4: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/4.jpg)
Brain metastases
Propensity to metastasize
• Melanoma 50%
• Lung carcinoma 25%
• Brest Carcinoma 25%
• Renal cell carcinoma 15%
• Colon carcinoma 5%
![Page 5: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/5.jpg)
Brain Metastases
• Melanoma and Lung tend to have multiple brain lesions
• Breast, Colon and Renal cell carcinoma tend to present a single brain metastasis
• The interval between the diagnosis of the primary cancer and brain metastases depends on histology of the primary cancer: Breast cancer (longer) 3 years, Lung (shorter) 4-10 months.
Delattre JY 1988, Byrne TN 1983, Madajewicz S 1984,
Black P 2000
![Page 6: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/6.jpg)
Multiple Brain Metastases (diagnosis)
• > 60% with MRI
• 40-50% with CT
![Page 7: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/7.jpg)
Surgical Treatment Goal
• To relieve symptoms
• To provide long term local control
• To confirm histological diagnosis (through surgery only)
![Page 8: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/8.jpg)
Surgical techniques
• Total removal
• «En bloc» resection (when feasible)
• Microsurgery
• Intraoperative image guidance (Neuronavigation,
Ultrasound, iMRI)
• Intraoperative neuromonitoring (SEP, MEP,
Cortical stimulation, Awake surgery)
![Page 9: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/9.jpg)
Surgery vs SRS
![Page 10: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/10.jpg)
Surgical patients selection
1. Clinical status (expected survival time)
2. Number of lesions
3. Size
4. Location
5. Histology of primary tumor (radiosensitivity)
![Page 11: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/11.jpg)
• RPA classification system (class I-III) takes into account KPS, primary tumor control, age, extracranial spread
• Graded Prognostic Assesment GPA (score 0-4) takes into account number of metastasis
• Disease Specific-GPA takes into account primary tumor type
Clinical status
![Page 12: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/12.jpg)
Clinical status
Unfavorable prognostic factors in brain metastases
• KPS <70
• Uncontrolled primary tumor
• Age >65 yrs
• Presence of systemic metastases
![Page 13: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/13.jpg)
Clinical status Karnofsky Scale
![Page 14: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/14.jpg)
Number of metastases
Single brain metastases are the best candidates for surgery
«Significant overall survival and functional indipendence advantage in the surgery + WBRT group vs. WBRT group» (Class I evidence)
(indipendent favorable predictive factors are total removal and increased interval between diagnosis of primary tumor and metastasis)
Patchell RA et al. 1990 N Engl J Med 322(8):494-500
Vecht CJ et al. 1993 Ann Neurol 33 (6):583-90
![Page 15: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/15.jpg)
Number of metastases
Presence of Multiple Brain Metastasesgenerally is a surgical contraindication
No difference in mortality-morbility between single or multiple resection and no difference in overall survival if :
number of brain lesions = o <3,
age < 60y,
KPS >70,
complete surgical resection (Class III evidence)
Bindal RK, 1993
![Page 16: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/16.jpg)
“In presence of multiple lesions, if one dominant lesion causing mass effect is life threatening or reduces the quality of life resection of the dominant lesion is preferable”
Sawaya R Intracranial Metastases Current Management Strategies, 2008
Number of metastases
![Page 17: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/17.jpg)
Size of brain metastasis
• For single lesion greater than 3 cm in maximum diameter surgery is the first therapeutic option
• For single lesion with diameter < 1cm SRS is the first therapeutic option.
• For single lesion with diameter 1-3 cm surgical indication is debatable (surgery vs. SRS )
Bindal RK 1993, Sawaya R 1998, Patchel RA 1998, Iwadate Y 2000, Muller R 2009
![Page 18: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/18.jpg)
Location of brain metastasis
The brain metastases are localized in the arterial border zones and in the junction between cortex and white matter
Usually they have a hematogenous diffusion;local extension can also occur:
• 80% cerebral hemispheres• 15% cerebellum• 5% basal ganglia, thalamus and brain stem
Delattre JY 1988, Posner JB 1995, Shaffrey ME 2004, Brem SN 2009, Mongan JP 2009.
![Page 19: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/19.jpg)
Location of brain metastasis
• Surgical mortality-morbidity depends principally by the tumor location.
• Also complete tumor removing depends principally by the tumor location (superficial/deep , eloquent/near eloquent area)
• Non surgical candidate: brain stem, thalamus and basal ganglia lesions
Bindal RK 1993, Vecht CJ 1993, Sawaya R 1998,
Patchel RA 1998, Iwadate Y 2000, Muller R 2009
![Page 20: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/20.jpg)
Histology of primary tumor
Brain metastases with high radiosensitivity are not candidated for surgery (Lang FF 1996, Brown PD 2002 )
High sensitivity
Intermediate sensitivity
Poor sensitivity
Lymphoma Breast Melanoma
Germinoma Lung (non small cell)
Kidney
Lung ( Small cell) Colon Sarcoma
![Page 21: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/21.jpg)
Other factors evaluated in surgical decision-making
• Marked peritumoral edema
• Hydrocephalus
• Cystic or necrotic lesion
• Neurological syndrome (reversibility)
• Diagnostic uncertainty
• Failure of previous radiotherapy
• Leptomeningeal spread
![Page 22: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/22.jpg)
Hypernephroma L F metastasis (surgery)
![Page 23: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/23.jpg)
Lung adenocarcinoma L T-P metastasis (surgery)
![Page 24: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/24.jpg)
Hypernephroma L F metastasis (surgery)
![Page 25: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/25.jpg)
Lung spino-cellular carcinoma L T-O metastasis (surgery)
![Page 26: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/26.jpg)
Lung adenocarcinoma R T metastasis (surgery)
![Page 27: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/27.jpg)
Lung adenocarcinoma R prerolandic metastasis (surgery)
![Page 28: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/28.jpg)
Lung adenocarcinoma R T metastasis (surgery)
![Page 29: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/29.jpg)
Breast carcinoma L parasagittal metastasis (surgery)
![Page 30: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/30.jpg)
Breast carcinoma
Double cerebellar metastases (surgery)
![Page 31: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/31.jpg)
Melanoma Multiple metastases (surgery)
![Page 32: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/32.jpg)
Lung adenocarcinoma Brainstem metastasis (SRS)
![Page 33: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/33.jpg)
Breast carcinoma L parietal metastasis (SRS)
![Page 34: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/34.jpg)
Lung adenocarcinoma Mid-Callosal metastasis (SRS)
![Page 35: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/35.jpg)
Breast carcinoma R T-polar metastasis (SRS)
![Page 36: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/36.jpg)
Our recent surgical series (2009-2014) 83 cases
• 38/83 lung cancer (46%)
• 18/83 breast cancer (22%)
• 14/83 melanoma (16%)
• 8/83 colonrectal cancer (10%)
• 5/83 kidney cancer (6%)
![Page 37: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/37.jpg)
Our recent surgical series (2009-2014) 83 cases
• In 76 of 83 cases removal of a single metastasis (in 7of 83 multiple metastases )
• In only 3 cases total removal of multiple metastases ( single procedure)
• 6 of 8 members of the surgical staff involved as first surgeon
• Routine use of microneurosurgery and neuronavigation ( no IONM; no iMRI)
![Page 38: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/38.jpg)
• 1 death from PE
• 1 moderate hemiparesis
• 2 transient neurological dysfunctions (aphasia, confusional state)
• 1 deep infection (successful re-operation)
• 4 reversible general complications (pneumonia, PE, flebothrombosis, sepsis)
Mortality-Permanent morbidity < 3%
Surgical complications ( within 30 days )
in 83 cases
![Page 39: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/39.jpg)
5-year and median ST in our 10–year surgical series (119 cases from 2005 to 2014)
• Breast 23,8 % 29m
• Lung 21,4% 10m
• Kidney 20 % 28m
• Skin 9,3% 5m
• Colon 0 % 5m
![Page 40: Brain Metastases The Role of Surgery Dr Orazio Arena Direttore U.O. Neurochirurgia Ospedale A.Manzoni Lecco](https://reader037.vdocuments.site/reader037/viewer/2022110100/56649e375503460f94b2812e/html5/thumbnails/40.jpg)
Conclusions
• The surgical procedure for single metastases is easy and has very low morbidity
• In our surgical series there is a significative percentage of patients with a long (>5 years) survival after surgery, in the order of 20%
• The key to success of this surgery lies in the correct selection of patients, on the basis of a multidisciplinary assessment; the respective roles of surgery and SRS must be better defined