Very Large Metastases to the Brain: Retrospective Study on Outcomes of Surgical Management

The incidence of brain metastases is rising. To our knowledge, no published study focuses exclusively on brain metastases larger than 4 cm. We present our surgical outcomes for patients with brain metastases larger than 4 cm.

This is a retrospective chart review of inpatient data at our institution from January 2006 to September 2015. Primary end points included overall survival, progression-free survival, and local recurrence rate.

Sixty-one patients had a total of 67 brain metastases larger than 4 cm: 52 were supratentorial and 15 were infratentorial. Forty-three patients underwent surgical resection. Average duration of disease freedom after resection was 4.79 months (range, 0-30 months). Excluding patients with residual on immediate postoperative magnetic resonance imaging, the average rate of local recurrence was 7 months (range, 1-14 months). Overall survival after surgery excluding patients who chose palliation in the immediate postoperative period averaged 8.76 months (range, 1-37 months). Thirty-five of 43 patients (81.4%) had stable or improved neurologic examinations postoperatively. Six patients (13.95%) developed surgical complications. There were 3 major complications (6.98%): 2 pseudomeningoceles required intervention and 1 postoperative hematoma required external ventricular drain placement. There were 3 minor complications (6.98%): 1 self-limited pseudomeningocele, 1 subgaleal fluid collection, and 1 postoperative seizure.

Surgery resulted in stable or improved neurologic examination in 81.4% of cases. On statistical analysis, significantly increased overall survival was noted in patients undergoing surgical resection, and those with higher Karnofsky Performance Scale and lower number of brain metastases at presentation. There is a need for further studies to evaluate management of brain metastases larger than 4 cm.