intracranial_metastases_surgical_technique

Intracranial Metastases Surgical Technique

see Phang I, Leach J, Leggate JRS, Karabatsou K, Coope D, D'Urso PI. Minimally Invasive Resection of Brain Metastases. World Neurosurg. 2019 Jun 21. pii: S1878-8750(19)31643-2. doi: 10.1016/j.wneu.2019.06.091. [Epub ahead of print] PubMed PMID: 31233927.


The primary aims for surgical treatment of brain metastases are to improve neurological performance and to prolong overall survival. With the introduction of image-guided and microscopic surgical techniques, these goals have become more readily attainable 1).

As novel methods of localization and resection become available, the surgical repertoire is enhanced, and treatment is greatly improved. However, depending on the clinical course of each individual patient, certain surgical techniques may engender a better outcome than others 2).

Control of local recurrence is an important aspect in the management of brain metastases. As many as 46% of resected lesions eventually recur 3).

However, the method of resection has significant impact on local recurrence rate. Tumors that were resected in a piecemeal fashion (without violating the tumor capsule) have been found to have a recurrence rate 1.7 times higher than those removed en bloc (circumferential resection). The 14% local recurrence rate for en bloc resected tumors most likely reflects less intraoperative tumor spillage, compared with piecemeal procedures 4).

En bloc resections are particularly useful in resecting posterior fossa metastases and lesions in contact with the CSF pathway, tumors that are highly prone to lemptomeningeal spread following surgery. 5) 6).

However, piecemeal resection may be unavoidable in some situations, as in cases where the tumor is adherent to or infiltrating eloquent brain regions, or when the lesion is extremely friable 7).

In these situations, it is not uncommon for local recurrence, even with postoperative MRI confirmation of complete tumor removal. Following gross total resections of well-circumscribed brain tumors, microscopic infiltrates are often left on the tumor bed 8).

To prevent this residual cancer, Yoo et al. suggested a novel technique, microscopic total resection, in which apparently normal-looking parenchyma is suctioned to a depth of 5 mm by ultrasonic aspiration. In their prospective assessment, microscopic total resection led to a decrease in metastatic local recurrence (29% one year local recurrence rate, as compared with 59% after gross total resection, P = 0.01). Thus, en bloc resection and microscopic total resection techniques are highly effective in limiting local recurrence, and their use should be assessed in applicable clinical scenarios 9).see Phang I, Leach J, Leggate JRS, Karabatsou K, Coope D, D'Urso PI. Minimally Invasive Resection of Brain Metastases. World Neurosurg. 2019 Jun 21. pii: S1878-8750(19)31643-2. doi: 10.1016/j.wneu.2019.06.091. [Epub ahead of print] PubMed PMID: 31233927.


The primary aims for surgical treatment of brain metastases are to improve neurological performance and to prolong overall survival. With the introduction of image-guided and microscopic surgical techniques, these goals have become more readily attainable 10).

As novel methods of localization and resection become available, the surgical repertoire is enhanced, and treatment is greatly improved. However, depending on the clinical course of each individual patient, certain surgical techniques may engender a better outcome than others 11).

Control of local recurrence is an important aspect in the management of brain metastases. As many as 46% of resected lesions eventually recur 12).

However, the method of resection has significant impact on local recurrence rate. Tumors that were resected in a piecemeal fashion (without violating the tumor capsule) have been found to have a recurrence rate 1.7 times higher than those removed en bloc (circumferential resection). The 14% local recurrence rate for en bloc resected tumors most likely reflects less intraoperative tumor spillage, compared with piecemeal procedures 13).

En bloc resections are particularly useful in resecting posterior fossa metastases and lesions in contact with the CSF pathway, tumors that are highly prone to lemptomeningeal spread following surgery. 14) 15).

However, piecemeal resection may be unavoidable in some situations, as in cases where the tumor is adherent to or infiltrating eloquent brain regions, or when the lesion is extremely friable 16).

In these situations, it is not uncommon for local recurrence, even with postoperative MRI confirmation of complete tumor removal. Following gross total resections of well-circumscribed brain tumors, microscopic infiltrates are often left on the tumor bed 17).

To prevent this residual cancer, Yoo et al. suggested a novel technique, microscopic total resection, in which apparently normal-looking parenchyma is suctioned to a depth of 5 mm by ultrasonic aspiration. In their prospective assessment, microscopic total resection led to a decrease in metastatic local recurrence (29% one year local recurrence rate, as compared with 59% after gross total resection, P = 0.01). Thus, en bloc resection and microscopic total resection techniques are highly effective in limiting local recurrence, and their use should be assessed in applicable clinical scenarios 18).


1) , 10)
Wadley J, Dorward N, Kitchen N, Thomas D. Pre-operative planning and intra-operative guidance in modern neurosurgery: a review of 300 cases. Ann R Coll Surg Engl. 1999 Jul;81(4):217-25. PubMed PMID: 10615186; PubMed Central PMCID: PMC2503267.
2) , 11)
Yaeger KA, Nair MN. Surgery for brain metastases. Surg Neurol Int. 2013 May 2;4(Suppl 4):S203-8. doi: 10.4103/2152-7806.111297. Print 2013. PubMed PMID: 23717791; PubMed Central PMCID: PMC3656566.
3) , 4) , 7) , 12) , 13) , 16)
Patel TR, Knisely JP, Chiang VL. Management of brain metastases: surgery, radiation, or both? Hematol Oncol Clin North Am. 2012 Aug;26(4):933-47. doi: 10.1016/j.hoc.2012.04.008. Epub 2012 May 16. Review. PubMed PMID: 22794291.
5) , 14)
Ahn JH, Lee SH, Kim S, Joo J, Yoo H, Lee SH, Shin SH, Gwak HS. Risk for leptomeningeal seeding after resection for brain metastases: implication of tumor location with mode of resection. J Neurosurg. 2012 May;116(5):984-93. doi: 10.3171/2012.1.JNS111560. Epub 2012 Feb 17. PubMed PMID: 22339161.
6) , 15)
Suki D, Abouassi H, Patel AJ, Sawaya R, Weinberg JS, Groves MD. Comparative risk of leptomeningeal disease after resection or stereotactic radiosurgery for solid tumor metastases to the posterior fossa. J Neurosurg. 2008 Feb;108(2):248-57. doi: 10.3171/JNS/2008/108/2/0248. PubMed PMID: 18240919.
8) , 17)
Sundaresan N, Galicich JH. Surgical treatment of brain metastases. Clinical and computerized tomography evaluation of the results of treatment. Cancer. 1985 Mar 15;55(6):1382-8. PubMed PMID: 3971308.
9) , 18)
Yoo H, Kim YZ, Nam BH, Shin SH, Yang HS, Lee JS, Zo JI, Lee SH. Reduced local recurrence of a single brain metastases through microscopic total resection. J Neurosurg. 2009 Apr;110(4):730-6. doi: 10.3171/2008.8.JNS08448. PubMed PMID: 19072310.
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