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Neurosurgical management of metastases in the central nervous system

Nature Reviews Clinical Oncology volume 9, pages 79–86 (2012)Cite this article

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Abstract

Metastases in the central nervous system (CNS) are identified in up to 30% of patients at autopsy. Rates of CNS involvement in metastatic cancer are believed to be increasing, possibly owing to better control of systemic disease with novel chemotherapies or improved metastasis detection. The neurosurgical treatment of patients with metastatic cancer is an integral component of multimodality therapy for brain and spinal metastases. Survival benefit has been demonstrated for the addition of open surgery as well as the use of stereotactic radiosurgery (SRS) to whole-brain radiation therapy for treatment of patients with isolated cranial and spinal metastases compared with whole-brain radiation therapy alone. New clinical trials that directly compare open surgical procedures with SRS are underway, as are trials examining the role of neurosurgical procedures, such as vertebroplasty and kyphoplasty, in association with radiotherapy as methods for pain control in cancer patients with metastatic lesions in the spinal column. In this article, I review data from current randomized clinical trials that examine the role of neurosurgical intervention in the treatment of patients with CNS metastases.

Key Points

  • Data from randomized clinical trials (RCTs) suggest that for individuals with one surgically accessible intracranial metastasis and good performance score, surgery with whole-brain radiation therapy (WBRT) is preferable to WBRT alone

  • Similarly, findings from RCTs indicate that for patients with a single intracranial metastasis and good performance score, stereotactic radiosurgery (SRS) with WBRT is preferable to WBRT alone

  • WBRT does not seem to be associated with a benefit in survival, but does seem to be associated with increased time-to-recurrence at both local and distant brain sites

  • RCTs comparing surgery with SRS, or comparing surgery alone with surgery followed by SRS, are ongoing; both modalities are currently considered reasonable options for patients with a good performance status

  • Data of the sole RCT in which the use of surgery for patients with spinal metastases was examined suggest a benefit with respect to functional independence and overall survival

  • RCTs using permutations of radiotherapy and vertebroplasty or kyphoplasty as interventions for pain from spinal metastases are underway; results will be reported in the future

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Figure 1: MRI of a patient with an intracranial lesion.
Figure 2: An adult woman with a forearm melanoma that was resected 2 years earlier presented with left-hand clumsiness and writing difficulties.
Figure 3: Neurosurgery on the basis of functional MRI and diffusion tensor imaging.

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Authors and Affiliations

  1. Yale University, School of Medicine, 60 College Street, New Haven, 06511, CT, USA

    Elizabeth B. Claus

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Claus, E. Neurosurgical management of metastases in the central nervous system. Nat Rev Clin Oncol 9, 79–86 (2012). https://doi.org/10.1038/nrclinonc.2011.179

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