Introduction Management of patients with intracranial metastases from an unknown primary tumor (CUP) varies compared to those with metastases of known primary tumor origin (CKP). The National Institute for Health and Care Excellence (NICE) recognizes the current lack of research to support the management of CUP patients with brain metastases. The primary aim was to compare survival outcomes of CKP and CUP patients undergoing early resection of intracranial metastases to understand the efficacy of surgery for patients with CUP. Methods A retrospective study was performed, wherein patients were identified using a pathology database. Data was collected from patient notes and trust information services. Surgically managed patients during a 10-year period aged over 18 years, with a histological diagnosis of intracranial metastasis, were included. Results 298 patients were identified, including 243 (82.0%) CKP patients and 55 (18.0%) CUP patients. Median survival for CKP patients was 9 months (95%CI 7.475-10.525); and 6 months for CUP patients (95%CI 4.263-7.737, p = 0.113). Cox regression analyses suggest absence of other metastases (p = 0.016), age (p = 0.005), and performance status (p = 0.001) were positive prognostic factors for improved survival in cases of CUP. The eventual determination of the primary malignancy did not affect overall survival for CUP patients. Conclusions There was no significant difference in overall survival between the two groups. Surgical management of patients with CUP brain metastases is an appropriate treatment option. Current diagnostic pathways specifying a thorough search for the primary tumor pre-operatively may not improve patient outcomes.

INTRODUCTION: Over 50% of patients with meningioma do not present with epileptic seizures. Anti-epileptic drugs (AEDs) cause adverse effects in ~20% of patients. Guidelines recommend against routine use of prophylactic AEDs. The aim of this study was to evaluate the use of prophylactic AEDs in meningioma surgery in the UK.MATERIALS AND METHODS: Online survey of UK neurosurgeons to determine: (a) use of prophylactic AED; (b) preferred AED, dose and duration of use; (c) tumour location and radiological factors that influence use of AED; (d) willingness to participate in a future randomised controlled trial.RESULTS: 60 completed surveys from 25 neurosurgical centres. Use of prophylactic AED was 'almost never' in 37/61 (61%); 'rarely' 10/61 (16%); 'often' 8/61 (13%) and 'almost always' 6/61 (10%). 42 surgeons had prescribed AEDs at some point. Sphenoid (24/49; 49%) and olfactory (17/49; 35%) location, oedema (26/49; 53%) and mass effect/midline shift (20/49; 41%) were factors associated with prophylactic AED use. Leviteracetam (n=23) and phenytoin (n=18) were the commonest AEDs used. Commonest duration of AED prescription was 7 days (n=18) and 14 days (n=8), but ranged from single dose at surgery to 3 months. 80% of surgeons would participate in a randomised controlled trial. CONCLUSIONS: Most UK neurosurgeons follow guidelines and do not routinely prescribe prophylactic AEDs. Sphenoid and olfactory meningiomas and those with oedema are more likely to receive prophylactic AEDs which suggests neurosurgeons are more concerned about the consequences of seizures in these patients. A randomised controlled trial is required to provide class I evidence of those patients that may benefit from prophylactic AEDs in meningioma surgery.

No abstract