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  • Author or Editor: Raymond Sawaya x
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Akash J. Patel, Dima Suki, Mustafa Aziz Hatiboglu, Vikas Y. Rao, Benjamin D. Fox and Raymond Sawaya


Brain metastases are the most common intracranial neoplasms and are on the increase. As radiation side effects are increasingly better understood, more patients are being treated with surgery alone with varying outcomes. The authors previously reported that en bloc resection of a single brain metastasis was associated with decreased incidences of leptomeningeal disease and local recurrence compared with piecemeal resection. However, en bloc resection is often feared to cause an increased incidence of postoperative complications. This study aimed to answer this question.


The authors reviewed data from patients with a previously untreated single brain metastasis, who were treated with resection at The University of Texas M.D. Anderson Cancer Center (1993–2012). Data related to the patient, tumor, and methods of resection were obtained. Discharge Karnofsky Performance Scale (KPS) scores and 30-day postoperative complications were noted. Complications were considered major when they persisted for longer than 30 days, resulted in hospitalization or prolongation of hospital stay, required aggressive treatment, and/or were life threatening.


During the study period, 1033 eligible patients were identified. The median age was 58 years, 83% had a KPS score greater than 70, and 81% were symptomatic at surgery. Sixty-two percent of the patients underwent en bloc resection of their tumor, and 38% underwent piecemeal resection. There were significant differences between the 2 groups in terms of preoperative tumor volume, tumor functional grade, and symptoms at presentation, among others. The overall complication rates were 13% for patients undergoing en bloc resection and 19% for patients undergoing piecemeal resection (p = 0.007). The incidences of major complications and neurological complications were also significantly different. There was a trend in the same direction for major neurological complications, although it was not significant. Among patients undergoing piecemeal resection of tumors in eloquent cortex, 24% had complications (13% had major, 18% had neurological, 9% had major neurological, and 13% had select neurological complications; 4% died within 1 month of surgery). Among those undergoing en bloc resection of such tumors, 11% had complications (6% had major, 8% had neurological, 4% had major neurological, and 4% had select neurological; 2% died within 1 month of surgery). The differences in overall, major, neurological, and select neurological complications were statistically significant, but 1-month mortality and major neurological complications were not. In addition, within subcategories of tumor volume, the incidence of various complications was generally higher for patients undergoing piecemeal resection than for those undergoing en bloc resection.


The authors' results indicate that postoperative complication rates are not increased by en bloc resection, including for lesions in eloquent brain regions or for large tumors. This gives credence to the idea that en bloc resection of brain metastases, when feasible, is at least as safe as piecemeal resection.

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Akash J. Patel, Dima Suki, Mustafa Aziz Hatiboglu, Hiba Abouassi, Weiming Shi, David M. Wildrick, Frederick F. Lang and Raymond Sawaya


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.


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.


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.


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.

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Oral Presentations

2010 AANS Annual Meeting Philadelphia, Pennsylvania May 1–5, 2010