Management of Cerebral Metastases: The Role of Surgery

BACKGROUND: Metastatic brain tumors represent the most common neurological complication in patients with systemic cancer. They are predominantly cerebrally located and constitute a significant source of morbidity and mortality. The overall incidence of brain metastases exceeds that of all other intracranial tumors, and as improved systemic cancer treatments have extended patients' lives, this number is rising. METHODS: The role of surgery in the management of cerebral metastases is reviewed by considering patient selection criteria, surgical approaches to metastases, intraoperative adjuncts, whole-brain irradiation as a postoperative adjuvant, resection of multiple vs single metastases, and the relative roles of stereotactic radiosurgery and conventional surgery. RESULTS: Surgical resection of single or multiple metastases can be effective management for patients with otherwise good prognoses, providing all the known metastases can be removed without producing significant neurologic deficit. Radiosurgery, an alternate approach, can be used for smaller or inaccessible tumors. CONCLUSIONS: The presence of multiple brain metastases does not automatically contraindicate surgery because in properly selected patients, resection of multiple metastases can extend survival and enhance the quality of life. An awareness of how the modalities of open craniotomy, whole-brain radiotherapy, and stereotactic radiosurgery best complement each other will result in the best outcomes.