Combined Resection And Radiosurgery As The Initial Management For Multiple Metastatic Brain Tumors

In-Young Kim1, Shin Jung2, Tae-Young Jung2, Kyung-Sub Moon2, Seung-Jin Park2, Sam-Suk Kang2

1Hwasun, Korea, Republic of 2Chonnam National University Hwasun Hospital, Hwasun, Chonnam, Republic of Korea,

Keywords: gamma knife, resection, brain metastasis, outcome, cancer

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     Although randomized trials have reported that surgery plus whole brain radiotherapy (WBRT) for single cerebral metastasis showed better outcome, the role of consecutive WBRT after resection has been argued, especially in case of gross total resection. In radiosurgery, the treatable number of cerebral metastasis has increased. If we manage a patient who shows multiple cerebral metastases and one of the tumors is surgically indicated, which treatment modalities are initially indicated?
     We initially managed those patients with gross total resection for surgically indicated tumor(s) and consecutive gamma knife radiosurgery (GKR) for the other tumor(s) without WBRT.
     In the last 5 years, 23 patients with multiple cerebral metastases underwent resection and consecutive GKR to the other metastases one week after the surgery. Mean age was 58.3 year (range, 38 to 79), and male-to-female ratio was 1.3: 1. As the primary, lung cancer was 19, and the others 4. In 3 patients, multiple (2 - 4) tumors were resected, and the other patients (n = 20) underwent resection for a solitary large tumor.
     All the tumors resected were situated in cerebral and cerebellar hemisphere, and gross total resection was performed to them. The GKR was performed one week after the surgery to the other metastases. Total 107 tumors were managed with GKR. The mean volume was 1.8cc (range, 0.1 to 18.7), mean 22.2 Gray (range, 14 to 25) radiation dose was prescribed to the tumor margin. The follow up MRI was undertaken 2 or 3 months after these procedures.
     The progression-free periods was ranged from 2.1 to 33.5 months (mean: 8.4). The control rate of resected tumors was 93% (27 out of 29) and tumors treated with GKR 98% (105 out of 107). The distant failure was identified in 14 patients (61%). Among these patient, 7 patients underwent 2nd GKR or WBRT, but for the other 7 patients, only simple palliation was performed considering their poor general condition related to aggravated primary cancer.
     This is a retrospective study.
     To the selected patents with multiple metastatic brain tumors, combined resection and GKR could be applied as one of the initial managements reserving WBRT as a later adjuvant of salvage management.
     However, a further study including large number of patients and a prospective study with a control group should be needed.


Project Roles:

I. Kim (), S. Jung (), T. Jung (), K. Moon (), S. Park (), S. Kang ()