Introduction: The value of resecting multiple intracranial metastatic tumors, particularly when they are in noncontiguous anatomical regions, remains unclear. In analyzing a homogeneous population of patients with multiple CNS metastases, we sought to compare the clinical impact of resecting (1) only the largest metastatic tumor, (2) multiple tumors through multiple craniotomies during a single operation, and (3) multiple tumors in separate operative stages.

Methods: We identified 135 patients with multiple intracranial metastases who underwent 158 microsurgical resections of their tumors. Perioperative, clinical and radiographic data were retrospectively collected.

Results: One hundred and nine patients (81%) only had only one tumor resected (Group 1), 15 patients (11.1%) had a single procedure that removed at least two tumors using multiple craniotomies (Group 2), and 11 patients (8.1%) underwent staged resection of multiple metastases less than 30 days apart (Group 3). The most common tumor histologies were lung(63%), Melanoma (12.7%), and Breast (8.5%). Preoperatively, all three cohorts demonstrated comparable functionality based on median initial KPS: 77 (Group 1), 73.8 (Group 2), and 77.1 (Group 3). At hospital discharge, median KPS declined to 70, 61.4, and 70.7 respectively and, by 6-week clinical follow-up, KPS had improved to 75.1, 75.7, and 76.2 respectively. There were no permanent neurological deficits or mortality associated with any of the treatment groups.

Conclusions: A majority of metastatic brain tumor patients present with multiple tumors. Although the value of resecting a single metastasis for diagnosis and decompression is well-established, the safety and efficacy of resecting multiple tumors in anatomically-disparate regions remains unclear. Our findings suggest that multiple metastatic tumors can be resected safely, even when multiple craniotomies are necessary. Furthermore, staging these craniotomies appears to provide no added safety in comparison to performing multiple craniotomies during the course of a single operation.

Patient Care: It demonstrates that doing a staged procedure for removal of multiple metastatic lesions over several days does not provide any clinical benefit (nor any harm) than doing multiple craniotomies during the same surgery.

Learning Objectives: By the conclusion of this session participants should be able to: 1) Describe the importance of treating metastatic lesions, 2) Discuss in small groups the roles of multiple craniotomies for treatment of metastatic lesions, 3) Identify that staged and unstaged procedures provide equivalent results.

References: 1. Grossman et al., Predictors of Inpatient Death and Complications among Postoperative Elderly Patients with Metastatic Brain Tumors, Annals of Surgical Oncology, (2011)18(2) 521-528. 2. Zhang et al., A Review of Current Management of Brain Metastases, Annals of Surgical Oncology (2012)19(3):1043-1050. 3. Grossman et al., Outcome of Elderly Patients Undergoing Awake-Craniotomy for Tumor Resection, Annals of Surgical Oncology (2013) 20(5) 1722-1728