Neurosurgical management of metastases in the central nervous system

Metastases in the central nervous system (CNS) are identified in up to 30% of patients at autopsy. Rates of CNS involvement in metastatic cancer are believed to be increasing, possibly owing to better control of systemic disease with novel chemotherapies or improved metastasis detection. The neurosurgical treatment of patients with metastatic cancer is an integral component of multimodality therapy for brain and spinal metastases. Survival benefit has been demonstrated for the addition of open surgery as well as the use of stereotactic radiosurgery (SRS) to whole-brain radiation therapy for treatment of patients with isolated cranial and spinal metastases compared with whole-brain radiation therapy alone. New clinical trials that directly compare open surgical procedures with SRS are underway, as are trials examining the role of neurosurgical procedures, such as vertebroplasty and kyphoplasty, in association with radiotherapy as methods for pain control in cancer patients with metastatic lesions in the spinal column. In this article, I review data from current randomized clinical trials that examine the role of neurosurgical intervention in the treatment of patients with CNS metastases.