Surgical treatment of brain metastases

Authors: V. Vybíhal 1;  M. Smrčka 1;  I. Rošková 1;  T. Kazda 2;  A. Šprláková-Puková 3;  J. Šána 4;  O. Slabý 4;  M. Večeřa 4;  L. Křen 5;  P. Fadrus 1
Authors‘ workplace: Neurochirurgická klinika, LF MU a FN Brno ;  Klinika radiační onkologie LF MU, a Masarykův onkologický ústav, Brno 2;  Klinika radiologie a nukleární medicíny, LF MU a FN Brno 3;  Středoevropský technologický institut, MU, Brno 4;  Ústav patologie, LF MU a FN Brno 5
Published in: Cesk Slov Neurol N 2020; 83(2): 156-165
Category: Review Article
doi: 10.14735/amcsnn2020157


Brain metastases are serious complication of cancer. Progress in brain imaging, intraoperative electrophysiological monitoring and neurosurgical equipment have increased the extent of the resection and safety of neurosurgical operations while reducing mortality and morbidity. Surgical resection is still the first considered therapeutic option. It is especially recommended for patients with solitary cerebral metastasis in accessible localization, in good clinical conditions and with favourable prognosis. It is relatively contraindicated in the case of uncontrolled cancer disease, poor clinical conditions, in the case of radiosensitive tumours, poor disease prognosis and presence of more than three cerebral metastases. Surgical therapy for two or three metastases is also possible, but its role may be questionable in some aspects. General recommendations are not clearly defined in the case of recurrent metastases as well, and individual assessment is preferred based on the evaluation of the number of prognostic factors.

The Editorial Board declares that the manuscript met the ICMJE “uniform requirements” for biomedical papers.


brain metastasis – resection – surgical treatment


1. Mehta MP, Tsao MN, Whelan TJ et al. The American Society for Therapeutic Radiology and Oncology (ASTRO) evidence-based review of the role of radiosurgery for brain metastases. Int J Radiat Oncol Biol Phys 2005; 63 (1): 37–46. doi: 10.1016/j.ijrobp.2005.05.023.

2. Jemal A, Siegel R, Xu J et al. Cancer statistics 2010. CA Cancer J Clin 2010; 60 (5): 277–300. doi: 10.3322/caac. 20073.

3. Scoccianti S, Ricardi U. Treatment of brain metastases: review of phase III randomized controlled trials. Radiother Oncol 2012; 102 (2): 168–179. doi: 10.1016/j.radonc.2011.08.041.

4. Hatiboglu MA, Wildrick DM, Sawaya R. The role of surgical resection in patients with brain metastases. Ecancermedicalscience 2013; 7: 308. doi: 10.3332/ecancer.2013.308.

5. Markesbery WR, Brooks WH, Gupta GD et al. Treatment for patients with cerebral metastases. Arch Neurol 1978; 35 (11): 754–756. doi: 10.1001/archneur.1978.00500350058 012.

6. Horton J, Baxter DH, Olson KB. The management of metastases to the brain by irradiation and corticosteroids. Am J Roentgenol Radium Ther Nucl Med 1971; 111 (2): 334–336. doi: 10.2214/ajr.111.2.334.

7. Ruderman NB, Hall TC. Use of glucocorticoids in the palliative treatment of metastatic brain tumors. Cancer 1965; 18: 298–306. doi: 10.1002/1097-0142 (196503) 18: 3<298:: aid-cncr2820180306>; 2-h.

8. Sundaresan N, Galicich JH. Surgical treatment of brain metastases. Clinical and computerized tomography evaluation of the results of treatment. Cancer 1985; 55 (6): 1382–1388. doi: 10.1002/1097-0142 (19850315) 55: 6<; 1382:: AID-CNCR2820550637>; 3.0.CO; 2-Z.

9. Mandell L, Hilaris B, Sullivan M et al. The treatment of single brain metastasis from non-oat cell lung carcinoma. Surgery and radiation versus radiation therapy alone. Cancer 1986; 58 (3): 641–649.

10. Barker FG 2nd. Craniotomy for the resection of metastatic brain tumors in the U.S., 1988-2000: decreasing mortality and the effect of provider caseload. Cancer 2004; 100 (5): 999–1007. doi: 10.1002/cncr.20058.

11. Patchell RA, Tibbs PA, Walsh JW et al. A randomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med 1990; 322 (8): 494–500. doi: 10.1056/ NEJM199002223220802.

12. Vecht CJ, Haaxma-Reiche H, Noordijk EM et al. Treatment of single brain metastasis: radiotherapy alone or combined with neurosurgery? Ann Neurol 1993; 33 (6): 583–590. doi: 10.1002/ana.410330605.

13. Bindal AK, Bindal RK, Hess KR et al. Surgery versus radiosurgery in the treatment of brain metastasis. J Neurosurg 1996; 84 (5): 748–754. doi: 10.3171/jns.1996.84.5.0748.

14. Al-Zabin M, Ullrich WO, Brawanski A et al. Recurrent brain metastases from lung cancer: the impact of reoperation. Acta Neurochir (Wien) 2010; 152 (11): 1887–1892. doi: 10.1007/s00701-010-0721-7.

15. Sawaya R, Hammoud M, Schoppa D et al. Neurosurgical outcomes in a modern series of 400 craniotomies for treatment of parenchymal tumors. Neurosurgery 1998; 42 (5): 1044–1055. doi: 10.1097/00006123-199805000-00054.

16. Schödel P, Schebesch KM, Brawanski A et al. Surgical resection of brain metastases-impact on neurological outcome. Int J Mol Sci 2013; 14 (5): 8708–8718. doi: 10.3390/ijms14058708.

17. Norden AD, Wen PY, Kesari S. Brain metastases. Curr Opin Neurol 2005; 18 (6): 654–661. doi: 10.1097/ 00006123-199805000-00054.

18. Delattre JY, Krol G, Thaler HT et al. Distribution of brain metastases. Arch Neurol 1988; 45 (7): 741–744. doi: 10.1001/archneur.1988.00520310047016.

19. Svokos KA, Salhia B, Toms SA. Molecular biology of brain metastasis. Int J Mol Sci 2014; 15 (6): 9519–9530. doi: 10.3390/ijms15069519.

20. Schulz M, Salamero-Boix, Niesel K et al. Microenvironmental regulation of tumor progression and therapeutic response in brain metastasis. Front Immunol 2019; 10: 1713. doi: 10.3389/fimmu.2019.01713.

21. Hwang TL, Close TP, Grego JM et al. Predilection of brain metastasis in grey and white matter junction and vascular border zones. Cancer 1996; 77 (8): 1551–1555. doi: 10.1002/ (SICI) 1097-0142 (19960415) 77: 8<1551:: AID-CNCR19>3.0.CO; 2-Z.

22. Wesseling P, von Deimling A, Aldape K. Metastatic tumours of the CNS. 4th ed. Lyons, France: IARC Press 2007.

23. Berghoff AS, Rajky O, Winkler F et al. Invasion patterns in brain metastases of solid cancers. Neuro Oncol 2013; 15 (12): 1664–1672. doi: 10.1093/neuonc/not112.

24. Tsao MN, Xu W, Wong RK et al. Whole brain radiotherapy for the treatment of newly diagnosed multiple brain metastases. Cochrane Database Syst Rev 2018; 1: CD003869. doi: 10.1002/14651858.CD003869.pub4.

25. Kalkanis SN, Kondziolka D, Gaspar LE et al. The role of surgical resection in the management of newly diag-nosed brain metastases: a systematic review and evidence-based clinical practice guideline. J Neurooncol 2010; 96 (1): 33–43. doi: 10.1007/s11060-009-0061-8.

26. Krieger MD, Chandrasoma PT, Zee CS et al. Role of stereotactic biopsy in the diagnosis and management of brain tumors. Semin Surg Oncol 1998; 14 (1): 13–25. doi: 10.1002/ (sici) 1098-2388 (199801/02) 14: 1<13:: aid-ssu3>; 2-5.

27. Donato J, Campigotto F, Uhlmann EJ et al. Intracranial hemorrhage in patients with brain metastases treated with therapeutic enoxaparin: a matched cohort study. Blood 2015; 126 (4): 494–499. doi: 10.1182/blood-2015-02-626788.

28. Sundaresan N, Galicich JH. Surgical treatment of brain metastases. Clinical and computerized tomography evaluation of the results of treatment. Cancer 1985; 55 (6): 1382–1388. doi: 10.1002/1097-0142 (19850315) 55: 6<1382:: aid-cncr2820550637>; 2-z.

29. Soffietti R, Kocher M, Abacioglu UM et al. A European Organisation for Research and Treatment of Cancer phase III trial of adjuvant whole-brain radiotherapy versus observation in patients with one to three brain metastases from solid tumors after surgical resection or radiosurgery: quality-of-life results. J Clin Oncol 2013; 31 (1): 65–72. doi: 10.1200/JCO.2011.41.0639.

30. Hatiboglu MA, Chang EL, Suki D et al. Outcomes and prognostic factors for patients with brainstem metastases undergoing stereotactic radiosurgery. Neurosurgery 2011; 69 (4): 796–806. doi: 10.1227/NEU.0b013e31821d31de.

31. Yamamoto M, Serizawa T, Shuto T et al. Stereotactic radiosurgery for patients with multiple brain metastases (JLGK0901): a multi-institutional prospective observational study. Lancet Oncol 2014; 15 (4): 387–395. doi: 10.1016/S1470-2045 (14) 70061-0.

32. Niranjan A, Lunsford LD, Kano H. Guidelines for multiple brain metastases. Prog Neurol Surg 2019; 34: 100–109. doi: 10.1159/000493055.

33. Al-Shamy G, Sawaya R. Management of brain metastases: the indispensable role of surgery. J Neurooncol 2009; 92 (3): 275–282. doi: 10.1007/s11060-009-9839-y.

34. Hughes RT, Black PJ, Page BR et al. Local control of brain metastases after stereotactic radiosurgery: the impact of whole brain radiotherapy and treatment paradigm. J Radiosurg SBRT 2016; 4 (2): 89–96.

35. Bilger A, Frenzel F, Oehlke O et al. Local control and overall survival after frameless radiosurgery: a single center experience. Clin Transl Radiat Oncol 2017; 7: 55–61. doi: 10.1016/j.ctro.2017.09.007.

36. Muacevic A, Kufeld M, Wowra B et al. Feasibility, safety, and outcome of frameless image-guided robotic radiosurgery for brain metastases. J Neurooncol 2010; 97 (2): 267–274. doi: 10.1007/s11060-009-0023-1.

37. Lecomte DD, Lequesne J, Geffrelot J et al. Hypofractionated stereotactic radiotherapy for challenging brain metastases using 36 Gy in six fractions. Cancer Radiother 2019; 23 (8): 860–866. doi: 10.1016/j.canrad.2019.06.012.

38. O‘Beirn M, Benghiat H, Meade S et al. The expanding role of radiosurgery for brain metastases. Medicines (Basel) 2018; 5 (3). pii: E90. doi: 10.3390/medicines5030090.

39. Rades D, Haatanen T, Schild SE et al. Dose escalation beyond 30 grays in 10 fractions for patients with multiple brain metastases. Cancer 2007; 110 (6): 1345–1350. doi: 10.1002/cncr.22906.

40. Tsao MN, Rades D, Wirth A et al. Radiotherapeutic and surgical management for newly diagnosed brain metastasis (es): an American Society for Radiation Oncology evidence-based guideline. Pract Radiat Oncol 2012; 2 (3): 210 -225. doi: 10.1016/j.prro.2011.12.004.

41. Chang EL, Wefel JS, Hess KR et al. Neurocognition in patients with brain metastases treated with radiosurgery or radiosurgery plus whole-brain irradiation: a randomised controlled trial. Lancet Oncol 2009; 10 (11): 1037–1044. doi: 10.1016/S1470-2045 (09) 70263-3.

42. Kocher M, Soffietti R, Abacioglu U et al. Adjuvant wholebrain radiotherapy versus observation after radiosurgery or surgical resection of one to three cerebralmetastases: results of the eortc 22952-26001 study. J Clin Oncol 2011; 29 (2): 134–141. doi: 10.1200/JCO.2010.30.1655.

43. Conill C, Gimferrer JM, Marruecos J et al. Clinical outcome after surgical resection of lung metastases from melanoma. Clin Transl Oncol 2007; 9 (1): 48–52. doi: 10.1007/s12094-007-0009-4.

44. Andrews DW, Scott CB, Sperduto PW et al. Whole brain radiation therapy with or without stereotactic radiosurgery boost for patients with one to three brain metastases: phase III results of the RTOG 9508 randomised trial. Lancet 2004; 363 (9422): 1665–1672. doi: 10.1016/S0140-6736 (04) 16250-8.

45. Soffietti R, Rudà R, Trevisan E. Brain metastases: current management and new developments. Curr Opin Oncol 2008; 20 (6): 676–684. doi: 10.1097/CCO.0b013e32831186fe.

46. Zimmermann S, Dziadziuszko R, Peters S. Indications and limitations of chemotherapy and targeted agents in non-small cell lung cancer brain metastases. Cancer Treat Rev 2014; 40 (6): 716–722. doi: 10.1016/j.ctrv.2014.03.005.

47. Thomas AJ, Rock JP, Johnson CC et al. Survival of patients with synchronous brain metastases: an epidemiological study in southeastern Michigan. J Neurosurg 2000; 93 (6): 927–931. doi: 10.3171/jns.2000.93.6.0927.

48. Lagerwaard FJ, Levendag PC, Nowak PJ et al. Identification of prognostic factors in patients with brain metastases: a review of 1292 patients. Int J Radiat Oncol Biol Phys 1999; 43 (4): 795–803. doi: 10.1016/S0360-3016 (98) 00 442-8.

49. Venur VA, Ahluwalia MS. Prognostic scores for brain metastasis patients: use in clinical practice and trial design. Chin Clin Oncol 2015; 4 (2): 18. doi: 10.3978/j.issn.2304-3865.2015.06.01.

50. Schödel P, Schebesch KM, Brawanski A et al. Surgical resection of brain metastases – impact on neurological outcome. Int J Mol Sci 2013; 14 (5): 8708–8718. doi: 10.3390/ijms14058708.

51. Beauchesne P. Intrathecal chemotherapy for treatment of leptomeningeal dissemination of metastatic tumours. Lancet Oncol 2011; 11 (9): 871–879. doi: 10.1016/S1470-2045 (10) 70034-6.

52. Manon R, O’Neill A, Knisely J et al. Phase II trial of radiosurgery for one to three newly diagnosed brain metastases from renal cell carcinoma, melanoma, and sarcoma: an Eastern Cooperative Oncology Group study (E 6397). J Clin Oncol 2005; 23) 34): 8870–8876. doi: 10.1200/JCO.2005.01.8747.

53. Fuentes S, Delsanti C, Metellus P et al. Brainstem metastases: management using gamma knife radiosurgery. Neurosurgery 2006; 58 (1): 37–42. doi: 10.1227/01.neu.0000190655.95669.5c.

54. Paek SH, Audu PB, Sperling MR et al. Reevaluation of surgery for the treatment of brain metastases: review of 208 patients with single or multiple brain metastases treated at one institution with modern neurosurgical techniques. Neurosurgery 2005; 56 (5): 1021–1034.

55. Wronski M, Arbit E, McCormick B. Surgical treatment of 70 patients with brain metastases from breast carcinoma. Cancer 1997; 80 (9): 1746–1754. doi: 10.1002/ (sici) 1097-0142 (19971101) 80: 9<1746:: aid-cncr8>; 2-c.

56. Iwadate Y, Namba H, Yamaura A. Significance of surgical resection for the treatment of multiple brain metastases. Anticancer Res 2000; 20 (1B): 573–577.

57. Auslands K, Apškalne D, Bicāns K et al. Postoperative survival in patients with multiple brain metastases. Medicina (Kaunas) 2012; 48 (6): 281–285.

58. Boehling NS, Chang EL, Ma L et al. J Stereotactic radiosurgery for brain metastases: current status and future directions. Radiat Oncol 2012; 1: 245. doi: 10.1007/s13566-012-0043-x.

59. Vogelbaum MA, Suh JH. Resectable brain metastases. J Clin Oncol 2006; 24 (8): 1289–1994. doi: 10.1200/JCO.2005.04.6235.

60. Schebesch KM, Hoehne J, Hohenberger C et al. Fluorescein sodium-guided resection of cerebral metastases – experience with the first 30 patients. Acta Neurochir (Wien) 2015; 157 (6): 899–904. doi: 10.1007/s00701-015-2395-7.

61. Höhne J, Hohenberger C, Proescholdt M et al. Fluorescein sodium-guided resection of cerebral metastases-an update. Acta Neurochir (Wien) 2017; 159 (2): 363–367. doi: 10.1007/s00701-016-3054-3.

62. Kamp MA, Grosser P, Felsberg J et al. 5-aminolevulinic acid (5-ALA) -induced fluorescence in intracerebral metastases: a retrospective study. Acta Neurochir (Wien) 2012; 154 (2): 223–228. doi: 10.1007/s00701-011-1200-5.

63. Wadley J, Dorward N, Kitchen N et al. Pre-operative planning and intra-operative guidance in modern neurosurgery: a review of 300 cases. Ann R Coll Surg Engl 1999; 81 (4): 217–225.

64. Chua TH, See AA, Ang BT et al. Awake Craniotomy for resection of brain metastases: a systematic review. World Neurosurg 2018; 120: e1128–e1135. doi: 10.1016/j.wneu.2018.08.243.

65. Suki D, Abouassi H, Patel AJ et al. Comparative risk of leptomeningeal disease after resection or stereotactic radiosurgery for solid tumor metastasis to the posterior fossa. J Neurosurg 2008; 108 (2): 248–257. doi: 10.3171/JNS/2008/108/2/0248.

66. Patel AJ, Suki D, Hatiboglu MA et al. Factors influencing the risk of local recurrence after resection of a single brain metastasis. J Neurosurg 2010; 113 (2): 181–189. doi: 10.3171/2009.11.JNS09659.

67. Sawaya R, Hammoud M, Schoppa D et al. Neurosurgical outcomes in a modern series of 400 craniotomies for treatment of parenchymal tumors. Neurosurgery 1998; 42 (5): 1044–1055. doi: 10.1097/00006123-199805000-00054.

68. Kamp MA, Rapp M, Bühner J et al. Early postoperative magnet resonance tomography after resection of cerebral metastases. Acta Neurochir (Wien) 2015; 157 (9): 1573–1580. doi: 10.1007/s00701-015-2479-4.

69. GPA Index. [online]. Available from URL: http: //

70. Gaspar L, Scott C, Rotman M et al. Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy Oncology Group (RTOG) brain metastases trials. Int J Radiat Oncol Biol Phys 1997; 37 (4): 745–751.

71. Sperduto PW, Berkey B, Gaspar LE et al. A new prognostic index and comparison to three other indices for patients with brain metastases: an analysis of 1,960 patients in the RTOG database. Int J Radiat Oncol Biol Phys 2008; 70 (2): 510–514. doi: 10.1016/j.ijrobp.2007.06.074.

72. Sperduto PW, Kased N, Roberge D et al. Summary report on the graded prognostic assessment: an accurate and facile diagnosis-specific tool to estimate survival for patients with brain metastases. J Clin Oncol 2011; 30 (4): 419–425. doi: 10.1200/JCO.2011.38.0527.

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