Risk for leptomeningeal seeding after resection for brain metastases: implication of tumor location with mode of resection

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Surgical spillage has been one of the causative factors for the development of leptomeningeal seeding (LMS) after resection of brain metastases. In this paper, the authors' goal was to define the factors related to the development of LMS and to evaluate the difference according to tumor location.


The authors retrospectively analyzed 242 patients who had undergone resection for brain metastases. The factors investigated included tumor location with proximity to the CSF pathway (that is, contacting, involved with, or separated from the CSF pathway), the method of resection, and the use of the Cavitron Ultrasonic Surgical Aspirator (CUSA).


A total of 39 patients (16%) developed LMS at a median of 6.0 months (range 1–42 months) after resection. The risk of developing LMS was significantly higher in patients whose tumors were resected piecemeal than in those whose tumors were removed en bloc, with a hazard ratio (HR) of 4.08 (p < 0.01). The incidence of LMS was significantly higher in patients in whom the CUSA was used, and the HR was 2.64 (p < 0.01). The proximity of tumor to the CSF pathway in the involved group conferred an increased risk of LMS compared with the separated group (HR 11.36, p < 0.01). The risk of piecemeal resection for LMS was significant only in involved lesions (p < 0.01), and the use of the CUSA in both contact and involved lesions increased the incidence of LMS (p < 0.01 and p < 0.03, respectively).


The authors suggest that piecemeal resection using the CUSA should be limited because of the risk of postsurgical LMS, especially when the tumor is in contact with the CSF pathway.

Abbreviations used in this paper:CUSA = Cavitron Ultrasonic Surgical Aspirator; LMC = leptomeningeal carcinomatosis; LMS = leptomeningeal seeding; NSCLC = non–small cell lung cancer; SCLC = small cell lung cancer; WBRT = whole-brain radiotherapy.

Article Information

Address correspondence to: Ho-Shin Gwak, M.D., Ph.D., Neuro-Oncology Clinic, National Cancer Center, Korea, 323 Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do 410-769, Republic of Korea. email: halodoc@naver.com.

Please include this information when citing this paper: published online February 17, 2012; DOI: 10.3171/2012.1.JNS111560.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Classification of metastatic brain lesions according to their proximity to the CSF pathway. A and B: “Separated” lesions are those in which the entire margin of the lesion is surrounded by brain parenchyma. C and D: Lesions without intervening brain parenchyma between their margin and the pial surface (C) or ventricle wall (D) are defined as “contact” lesions. E and F: If the lesions show Gd enhancement of the pia mater (E) or ventricular wall (F), which is in continuity with the mass lesion, the lesion is designated as “involved.”

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    Kaplan-Meier curve for time to development of LMS after resection of brain metastases plotted for 244 patients in our study. The y axis represents the proportion of patients without LMS at each follow-up time on the x axis.

  • View in gallery

    Kaplan-Meier curves for time to development of LMS after resection of brain metastases according to proximity to the CSF pathway. Patients whose tumors were in contact (n = 43) or involved (n = 116) with the CSF pathway had a greater risk for developing LMS than patients whose tumors were separated from the pathway (n = 74), as evidenced by the Cox proportional hazard model (HR 7.36 [95% CI 1.56–34.7], p = 0.01; and HR 11.36 [95% CI 2.71–47.7], p < 0.01, respectively).

  • View in gallery

    Kaplan-Meier curves for time to development of LMS after resection of brain metastases according to the mode of resection. The y axis represents the proportion of patients without LMS at each follow-up time on the x axis. Patients who underwent piecemeal resection (n = 155) had a greater risk of developing LMS than those who underwent en bloc resection (n = 87) (HR estimated by the Cox proportional hazard model 4.08 [95% CI 1.38–5.04], p < 0.01).



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