Factors influencing the risk of local recurrence after resection of a single brain metastasis

Clinical article

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Object

Local recurrence (LR) of a resected brain metastasis occurs in up to 46% of patients. Postoperative whole-brain radiation therapy (WBRT) reduces that incidence. To isolate factors associated with the risk of LR after resection, the authors only studied patients who did not receive adjuvant radiotherapy.

Methods

The authors reviewed data from 570 cases involving patients who had undergone resection of a previously untreated single brain metastasis at The University of Texas M. D. Anderson Cancer Center between 1993 and 2006 without receiving postoperative WBRT. All tumors were measured preoperatively on MR images. The resection method (en bloc resection [EBR] or piecemeal resection [PMR]) was noted at the time of surgery. Predictors of LR were assessed using the Cox proportional hazards model.

Results

The median patient age was 58 years, 55% were male, and 88% had a Karnofsky Performance Scale Score ≥ 80. The most common primary cancers were those of the lung (28%), skin (melanoma, 21%), kidney (19%), and breast (11%). Piecemeal resection was performed in 201 patients (35%) and EBR in 369 (65%). Local recurrence developed in 84 patients (15%). The histological type of the primary cancer did not significantly predict LR; however, 7 of 22 patients with sarcoma developed LR (p = 0.16). The authors identified 2 variables that increased the risk of LR. Undergoing PMR carried a significantly higher LR risk than EBR (crude hazard ratio [HR] 1.7, 95% CI 1.1–2.6, p = 0.03). Tumors exceeding the median volume (9.7 cm3) had a significantly higher LR risk than those that were < 9.7 cm3 (crude HR 1.7; 95% CI 1.1–2.6; p = 0.02). In the multivariate analysis, small tumors removed by EBR had a significantly lower LR risk.

Conclusions

The LR risk of a single brain metastasis is influenced by biological factors (such as tumor volume) and treatments (such as the resection method). Early administration of postoperative WBRT may be particularly warranted when such negative tumor-related prognostic factors are noted or when treatment-related ones such as PMR are unavoidable.

Abbreviations used in this paper: CI = confidence interval; EBR = en bloc resection; HR = hazard ratio; KPS = Karnofsky Performance Scale; LR = local recurrence; PMR = piecemeal resection; WBRT = whole-brain radiation therapy.

Article Information

* Drs. Patel and Suki contributed equally to this work.

Address correspondence to: Raymond Sawaya, M.D., Department of Neurosurgery, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 442, Houston, Texas 77030. email: rsawaya@mdanderson.org.

Please include this information when citing this paper: published online December 25, 2009; DOI: 10.3171/2009.11.JNS09659.

© AANS, except where prohibited by US copyright law.

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Figures

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    Graph showing proportions of patients without LR stratified by tumor volume. The study group was divided into 4 equal quartiles of volume. Plot obtained from the multivariate Cox proportional hazards model analysis.

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    Graph showing proportions of patients without LR in patients who underwent PMR or EBR. Plot obtained from the multivariate Cox proportional hazards model analysis.

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    Graph showing proportions of patients without LR stratified by histological type of the primary tumor. Plot obtained from the multivariate Cox proportional hazards model analysis. GI = gastrointestinal.

  • View in gallery

    Multivariate analysis of LR in relation to tumor volume and resection method. Left: Graph showing proportions of patients without LR stratified by resection methodology (piecemeal or en bloc) in the group with tumor volume ≥ 9.71 cm3. Right: Graph showing proportions of patients without LR stratified by resection methodology in the group with tumor volume < 9.71 cm3. Bottom: Table demonstrating the risk of recurrence based on both tumor volume and resection method. Data obtained from the multivariate Cox proportional hazards model analysis.

References

  • 1

    Barker FG II: Craniotomy for the resection of metastatic brain tumors in the U.S., 1988–2000: decreasing mortality and the effect of provider caseload. Cancer 100:99910072004

    • Search Google Scholar
    • Export Citation
  • 2

    Barker FG II: Surgical and radiosurgical management of brain metastases. Surg Clin North Am 85:3293452005

  • 3

    Barnholtz-Sloan JSSloan AEDavis FGVigneau FDLai PSawaya RE: Incidence proportions of brain metastases in patients diagnosed (1973 to 2001) in the Metropolitan Detroit Cancer Surveillance System. J Clin Oncol 22:286528722004

    • Search Google Scholar
    • Export Citation
  • 4

    Baumert BGRutten IDehing-Oberije CTwijnstra ADirx MJDebougnoux-Huppertz RM: A pathology-based substrate for target definition in radiosurgery of brain metastases. Int J Radiat Oncol Biol Phys 66:1871942006

    • Search Google Scholar
    • Export Citation
  • 5

    Giordana MTCordera SBoghi A: Cerebral metastases as first symptom of cancer: a clinico-pathologic study. J Neurooncol 50:2652732000

    • Search Google Scholar
    • Export Citation
  • 6

    Mintz AHKestle JRathbone MPGaspar LHugenholtz HFisher B: A randomized trial to assess the efficacy of surgery in addition to radiotherapy in patients with a single cerebral metastasis. Cancer 78:147014761996

    • Search Google Scholar
    • Export Citation
  • 7

    Neves SMazal PRWanschitz JRudnay ACDrlicek MCzech T: Pseudogliomatous growth pattern of anaplastic small cell carcinomas metastatic to the brain. Clin Neuropathol 20:38422001

    • Search Google Scholar
    • Export Citation
  • 8

    Nieder CAstner STGrosu ALAndratschke NHMolls M: The role of postoperative radiotherapy after resection of a single brain metastasis. Combined analysis of 643 patients. Strahlenther Onkol 183:5765802007

    • Search Google Scholar
    • Export Citation
  • 9

    Patchell RATibbs PARegine WFDempsey RJMohiuddin MKryscio RJ: Postoperative radiotherapy in the treatment of single metastases to the brain: a randomized trial. JAMA 280:148514891998

    • Search Google Scholar
    • Export Citation
  • 10

    Patchell RATibbs PAWalsh JWDempsey RJMaruyama YKryscio RJ: A randomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med 322:4945001990

    • Search Google Scholar
    • Export Citation
  • 11

    Posner JBChernik NL: Intracranial metastases from systemic cancer. Adv Neurol 19:5795921978

  • 12

    Prentice RLKalbfleisch JDPeterson AV JrFlournoy NFarewell VTBreslow NE: The analysis of failure times in the presence of competing risks. Biometrics 34:5415541978

    • Search Google Scholar
    • Export Citation
  • 13

    Salvati MCervoni LDelfini R: Solitary brain metastases from non-oat cell lung cancer: clinical and prognostic features. Neurosurg Rev 19:2212251996

    • Search Google Scholar
    • Export Citation
  • 14

    Sawaya RHammoud MSchoppa DHess KRWu SZShi WM: Neurosurgical outcomes in a modern series of 400 craniotomies for treatment of parenchymal tumors. Neurosurgery 42:104410561998

    • Search Google Scholar
    • Export Citation
  • 15

    Suki DAbouassi HPatel AJSawaya RWeinberg JSGroves MD: Comparative risk of leptomeningeal disease after resection or stereotactic radiosurgery for solid tumor metastasis to the posterior fossa. J Neurosurg 108:2482572008

    • Search Google Scholar
    • Export Citation
  • 16

    Suki DHatiboglu MAPatel AJWeinberg JSGroves MDMahajan A: Comparative risk of leptomeningeal dissemination of cancer after surgery or stereotactic radiosurgery for a single supratentorial solid tumor metastasis. Neurosurgery 64:6646762009

    • Search Google Scholar
    • Export Citation
  • 17

    Sundaresan NGalicich JH: Surgical treatment of brain metastases. Clinical and computerized tomography evaluation of the results of treatment. Cancer 55:138213881985

    • Search Google Scholar
    • Export Citation
  • 18

    Vecht CJ: Clinical management of brain metastasis. J Neurol 245:1271311998

  • 19

    Vecht CJHaaxma-Reiche HNoordijk EMPadberg GWVoormolen JHHoekstra FH: Treatment of single brain metastasis: radiotherapy alone or combined with neurosurgery?. Ann Neurol 33:5835901993

    • Search Google Scholar
    • Export Citation
  • 20

    Yoo HKim YZNam BHShin SHYang HSLee JS: Reduced local recurrence of a single brain metastasis through microscopic total resection. Clinical article. J Neurosurg 110:7307362009

    • Search Google Scholar
    • Export Citation

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