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  • Very Large Metastases to the Brain: A Retrospective Study on Outcomes of Surgical Management.

    Final Number:

    Domenico A Gattozzi MD; Anthony Michael Alvarado MD; Collin S Kitzerow MD; Alexander Funkhouser; Roukoz B. Chamoun MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2017 Annual Meeting

    Introduction: Development of brain metastases from extracranial cancer continues to rise, related to advances in treatment of primary disease. No study to our knowledge focuses exclusively on brain metastases larger than 4 cm. We aimed to assess surgical outcomes of patients with 4 cm metastases.

    Methods: This is a retrospective chart review of inpatient data at our institution from January 2006 to September 2015. Sixty-one patients with brain metastases 4 cm or greater were identified. We excluded patients with prior invasive treatment. Primary endpoints were overall survival, progression-free survival, and local recurrence rate. Patients were followed until confirmed death or final follow-up.

    Results: Sixty-one patients had a total of 67 brain metastases larger than 4 cm: 52 supratentorial and 15 infratentorial. Forty-three patients underwent surgical resection. Average duration of disease freedom after resection was 4.79 months (range 0-30). Excluding patients with residual on immediate post-operative MRI, average rate of local recurrence was 7 months (range 1-14). Overall survival in the surgically treated group, excluding patients who chose palliation in the immediate postoperative period, averaged 8.76 months (range 1-37). Thirty-five (81.4%) of 43 patients had stable or improved neurological exams post-operatively. Six (13.95%) patients developed surgical complications. There were 3 (6.98%) major complications: 2 pseudomeningoceles requiring intervention, and 1 post-operative hematoma requiring external ventricular drain placement. The patient with the hematoma ultimately discharged to hospice. There were 3 (6.98%) minor complications: 1 self-limited pseudomeningocele, 1 subgaleal fluid collection which resolved after two needle aspirations, and 1 post-operative seizure which resolved after increase in antiepileptic drug regimen.

    Conclusions: We observed stability or improvement of neurological symptoms in the majority of cases (81.4%), with a mean recurrence rate of 7 months and mean overall survival of 8.76 months. There is need for prospective studies to further evaluate surgical management for brain metastases larger than 4 cm.

    Patient Care: The research presented in this abstract demonstrates preliminary data that surgery is a useful tool for brain metastases 4 cm or larger. We hope it will guide further research to determine the best treatment algorithm for very large metastases, and will encourage surgeons to consider surgery as a viable option in patients with metastases of this size.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) Understand the need and importance of studying the outcomes of surgery for very large intracranial metastases 2) Review our institution's results in surgical management of metastases 4 cm and larger 3) Consider surgery as an option for treatment of patients with metastases 4 cm and larger

    References: 1) Sinha, R. et al. The Evolving Clinical Management of Cerebral Metastases. European Journal of Surgical Oncology (2016), 10.1016/j.ejso.2016.10.006. 2) Gans, J.H. et al. The Role of Radiosurgery to the Tumor Bed After Resection of Brain Metastases. Neurosurgery. 2013 Mar;72(3):317-25; discussion 325-6. 3) Patel, A.J. et al. The Impact of Surgical Methodology on the Complication Rate and Functional Outcome of Patients with a Single Brain Metastasis. J Neurosurg. 2015 May;122(5):1132-43. 4) Sunderland, G.J. et al. Surgical Management of Posterior Fossa Metastases. Journal of Neurooncology 2016 Dec;130(3):535-542. Epub 2016 Sep 12.

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