Brain Tumor Res Treat.  2022 Jul;10(3):164-171. 10.14791/btrt.2022.0023.

Recent Update on Neurosurgical Management of Brain Metastasis

• Yoo J
• Park HH
• Kang SG
• Chang JH

• KMID: 2532249
• DOI: http://doi.org/10.14791/btrt.2022.0023

Abstract

Brain metastasis (BM), classified as a secondary brain tumor, is the most common malignant central nervous system tumor whose median overall survival is approximately 6 months. However, the survival rate of patients with BMs has increased with recent advancements in immunotherapy and targeted therapy. This means that clinicians should take a more active position in the treatment paradigm that passively treats BMs. Because patients with BM are treated in a variety of clinical settings, treatment planning requires a more sophisticated decision-making process than that for other primary malignancies. Therefore, an accurate prognostic prediction is essential, for which a graded prognostic assessment that reflects next-generation sequencing can be helpful. It is also essential to understand the indications for various treatment modalities, such as surgical resection, stereotactic radiosurgery, and whole-brain radiotherapy and consider their advantages and disadvantages when choosing a treatment plan. Surgical resection serves a limited auxiliary function in BM, but it can be an essential therapeutic approach for increasing the survival rate of specific patients; therefore, this must be thoroughly recognized during the treatment process. The ultimate goal of surgical resection is maximal safe resection; to this end, neuronavigation, intraoperative neuro-electrophysiologic assessment including evoked potential, and the use of fluorescent materials could be helpful. In this review, we summarize the considerations for neurosurgical treatment in a rapidly changing treatment environment.

Keyword

Brain neoplasms; Neurosurgery; Neoplasm grading

Figure

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  Fig. 1 Example of application of neuronavigation and diffusion tensor imaging (DTI) tractography. A: Neuronavigation showing the anatomical relationship between the tumor and the corticospinal tract (CST). B: Three-dimensional DTI tractography showing an intuitive perspective of the CST.

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  Fig. 2 Subcortical stimulation (SCS) during tumor resection. A: Sample monopolar stimulator for SCS. B: Application of SCS after tumor resection to estimate the distance to the corticospinal tract. C: Recording of muscle depolarization caused by SCS.

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  Fig. 3 Tumor resection using sodium fluorescein (A and B). A: Tumor and normal parenchyma under white light. B: Tumor and normal parenchyma under a yellow 560 nm filter. The tumor, where the blood-brain barrier was disrupted, is well stained by sodium fluorescein. Tumor resection using 5-aminolevulinic acid (5-ALA) (C and D). C: Tumor and normal parenchyma under white light. D: Tumor and normal parenchyma under a blue 400 nm filter. The tumor is well-stained with 5-ALA showing a strong red wavelength. CSF, cerebrospinal fluid.

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