The Impact of Postoperative Tumor Burden on Patients With Brain Metastases

Aftahy, Amir Kaywan; Barz, Melanie; Lange, Nicole; Baumgart, Lea; Thunstedt, Cem; Eller, Mario Antonio; Wiestler, Benedikt; Bernhardt, Denise; Combs, Stephanie E.; Jost, Philipp J.; Delbridge, Claire; Liesche‐Starnecker, Friederike

doi:10.3389/fonc.2022.869764

Cited by 10 publications

(20 citation statements)

References 42 publications

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“…This study shows that maximal EOR is critical for good long-term outcomes in older patients with BMs, as RTB = 0 significantly improves OS and local tumor control regardless of the cancer type. This finding is in accordance with recent investigations regarding the impact of RTB in younger patients (≤ 65 years) with brain metastases, which have proven low RTB to be a significant predictor for prolonged OS ( 23 ). Furthermore, it has been argued that maximal cytoreduction should be achieved, independent of the postoperative radiotherapy type ( 23 ).…”

Section: Discussionsupporting

confidence: 93%

“…This finding is in accordance with recent investigations regarding the impact of RTB in younger patients (≤ 65 years) with brain metastases, which have proven low RTB to be a significant predictor for prolonged OS ( 23 ). Furthermore, it has been argued that maximal cytoreduction should be achieved, independent of the postoperative radiotherapy type ( 23 ). Postoperative MRI should confirm EOR, as intraoperative estimates can misjudge complete resection.…”

Section: Discussionsupporting

confidence: 93%

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Brain metastases in the elderly – Impact of residual tumor volume on overall survival

et al. 2023

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BackgroundDue to demographic changes and an increased incidence of cancer with age, the number of patients with brain metastases (BMs) constantly increases, especially among the elderly. Novel systemic therapies, such as immunotherapy, have led to improved survival in recent years, but intracranial tumor progression may occur independently of a systemically effective therapy. Despite the growing number of geriatric patients, they are often overlooked in clinical trials, and there is no consensus on the impact of BM resection on survival.ObjectivesThe aim of this study was to analyze the impact of resection and residual tumor volume on clinical outcome and overall survival (OS) in elderly patients suffering from BM.MethodsPatients ≥ 75 years who had surgery for BM between April 2007 and January 2020 were retrospectively included. Residual tumor burden (RTB) was determined by segmentation of early postoperative brain MRI (72 h). Contrast-enhancing tumor subvolumes were segmented manually. “Postoperative tumor volume” refers to the targeted BMs. Impact of preoperative Karnofsky performance status scale (KPSS), age, sex and RTB on OS was analyzed. Survival analyses were performed using Kaplan-Meier estimates for the univariate analysis and the Cox regression proportional hazards model for the multivariate analysis.ResultsOne hundred and one patients were included. Median age at surgery was 78 years (IQR 76-81). Sixty-two patients (61%) had a single BM; 16 patients (16%) had two BMs; 13 patients (13%) had three BMs; and 10 patients (10%) had more than three BMs. Median preoperative tumor burden was 10.3 cm3 (IQR 5–25 cm3), and postoperative tumor burden was 0 cm3 (IQR 0–1.1 cm3). Complete cytoreduction (RTB = 0) was achieved in 52 patients (52%). Complete resection of the targeted metastases was achieved in 78 patients (78%). Median OS was 7 months (IQR 2–11). In univariate analysis, high preoperative KPSS (HR 0.986, 95% CI 0.973–0.998, p = 0.026) and small postoperative tumor burden (HR 1.025, 95% CI 1.002–1.047, p = 0.029) were significantly associated with prolonged OS. Patients with RTB = 0 survived significantly longer than those with residual tumor did (12 [IQR 5–19] vs. 5 [IQR 3–7] months, p = 0.007). Furthermore, prolongation of survival was significantly associated with surgery in patients with favorable KPSS, with an adjusted HR of 0.986 (p = 0.026). However, there were no significances regarding age.ConclusionsRTB is a strong predictor for prolonged OS, regardless of age or cancer type. Postoperative MRI should confirm the extent of resection, as intraoperative estimates do not warrant a complete resection. It is crucial to aim for maximal cytoreduction to achieve the best long-term outcomes for these patients, despite the fact the patients are advanced in age.

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Section: Discussionsupporting

confidence: 93%

Section: Discussionsupporting

confidence: 93%

Brain metastases in the elderly – Impact of residual tumor volume on overall survival

et al. 2023

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“…Especially, small and asymptomatic BMs are amenable to stereotactic radiosurgery (SRS), but large or symptomatic lesions require microsurgical resection for enduring symptom relief [9,10]. It has been shown that maximal tumor resection improves survival [11]. However, the local recurrence rate after resection is up to 50%, secondary to remnant tumor cells [12,13].…”

Section: Introductionmentioning

confidence: 99%

Low-Energy X-Ray Intraoperative Radiation Therapy (Lex-IORT) for Resected Brain Metastases: A Single-Institution Experience

Diehl

Pigorsch

Gempt

et al. 2022

Cancers

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Background: Resection followed by local radiation therapy (RT) is the standard of care for symptomatic brain metastases. However, the optimal technique, fractionation scheme and dose are still being debated. Lately, low-energy X-ray intraoperative RT (lex-IORT) has been of increasing interest. Method: Eighteen consecutive patients undergoing BM resection followed by immediate lex-IORT with 16–30 Gy applied to the spherical applicator were retrospectively analyzed. Demographic, RT-specific, radiographic and clinical data were reviewed to evaluate the effectiveness and safety of IORT for BM. Descriptive statistics and Kaplan–Meyer analysis were applied. Results: The mean follow-up time was 10.8 months (range, 0–39 months). The estimated local control (LC), distant brain control (DBC) and overall survival (OS) at 12 months post IORT were 92.9% (95%-CI 79.3–100%), 71.4% (95%-CI 50.2–92.6%) and 58.0% (95%-CI 34.1–81.9%), respectively. Two patients developed radiation necrosis (11.1%) and wound infection (CTCAE grade III); both had additional adjuvant treatment after IORT. For five patients (27.8%), the time to the start or continuation of systemic treatment was ≤15 days and hence shorter than wound healing and adjuvant RT would have required. Conclusion: In accordance with previous series, this study demonstrates the effectiveness and safety of IORT in the management of brain metastases despite the small cohort and the retrospective characteristic of this analysis.

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“…Moreover, changes in the molecular profile of the primary tumor established another important role of surgical resection in obtaining histopathological samples for further analysis (36). Maximal cytoreduction is an independent prognostic factor in the treatment of BM (37)(38)(39).…”

Section: Discussionmentioning

confidence: 99%

Enhancing outcomes: neurosurgical resection in brain metastasis patients with poor Karnofsky performance score - a comprehensive survival analysis

Goldberg,

Mondragon-Soto,

Altawalbeh

et al. 2024

Front. Oncol.

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BackgroundA reduced Karnofsky performance score (KPS) often leads to the discontinuation of surgical and adjuvant therapy, owing to a lack of evidence of survival and quality of life benefits. This study aimed to examine the clinical and treatment outcomes of patients with KPS < 70 after neurosurgical resection and identify prognostic factors associated with better survival.MethodsPatients with a preoperative KPS < 70 who underwent surgical resection for newly diagnosed brain metastases (BM) between 2007 and 2020 were retrospectively analyzed. The KPS, age, sex, tumor localization, cumulative tumor volume, number of lesions, extent of resection, prognostic assessment scores, adjuvant radiotherapy and systemic therapy, and presence of disease progression were analyzed. Univariate and multivariate logistic regression analyses were performed to determine the factors associated with better survival. Survival > 3 months was considered favorable and ≤ 3 months as poor.ResultsA total of 140 patients were identified. Median overall survival was 5.6 months (range 0-58). There was no difference in the preoperative KPS between the groups of > 3 and ≤ 3 months (50; range, 20–60 vs. 50; range, 10–60, p = 0.077). There was a significant improvement in KPS after surgery in patients with a preoperative KPS of 20% (20 vs 40 ± 20, p = 0.048). In the other groups, no significant changes in KPS were observed. Adjuvant radiotherapy was associated with better survival (44 [84.6%] vs. 32 [36.4%]; hazard ratio [HR], 0.0363; confidence interval [CI], 0.197–0.670, p = 0.00199). Adjuvant chemotherapy and immunotherapy resulted in prolonged survival (24 [46.2%] vs. 12 [13.6%]; HR 0.474, CI 0.263–0.854, p = 0.013]. Systemic disease progression was associated with poor survival (36 [50%] vs. 71 [80.7%]; HR 5.975, CI 2.610–13.677, p < 0.001].ConclusionNeurosurgical resection is an appropriate treatment modality for patients with low KPS. Surgery may improve functional status and facilitate further tumor-specific treatment. Combined treatment with adjuvant radiotherapy and systemic therapy was associated with improved survival in this cohort of patients. Systemic tumor progression has been identified as an independent factor for a poor prognosis. There is almost no information regarding surgical and adjuvant treatment in patients with low KPS. Our paper provides novel data on clinical outcome and survival analysis of patients with BM who underwent surgical treatment.

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The Impact of Postoperative Tumor Burden on Patients With Brain Metastases

Cited by 10 publications

References 42 publications

Brain metastases in the elderly – Impact of residual tumor volume on overall survival

Brain metastases in the elderly – Impact of residual tumor volume on overall survival

Low-Energy X-Ray Intraoperative Radiation Therapy (Lex-IORT) for Resected Brain Metastases: A Single-Institution Experience

Enhancing outcomes: neurosurgical resection in brain metastasis patients with poor Karnofsky performance score - a comprehensive survival analysis

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