Surgical resection of brain metastases from lung cancer

The role of surgical resection for brain metastases is evolving. The most common primary for brain metastases is lung; in the US in 1992, for example, there were nearly 40,000 deaths with symptomatic brain metastases from lung cancer. We reviewed a series of 25 consecutive patients with non small cell lung cancer (NSCLC) undergoing open resection of one or more symptomatic brain metastases to consider the role of open resection. Twenty-three of the 28 resected lesions were 3 cm or greater in diameter; 19 were solid and nine cystic. Surgical adjuncts included (where indicated): stereotactic biopsy, cyst drainage, and craniotomy; intra-operative ultrasound; and intra-operative evoked potential mapping of the sensorimotor area. Six patients underwent thoracotomy for resection of the lung primary (in all but one case, prior to craniotomy). Except for two patients who had whole brain radiation therapy (WBXRT) prior to referral to Neurosurgery, all patients underwent WBXRT (30 to 60 Gy) postoperatively. The mean survival from date of craniotomy was 13.1 months, with two patients still alive at ten and seventeen months post-craniotomy. Survival comparisons which were significantly different included (1) lung surgery versus no lung surgery (25.7 months versus 9.1 months, P < 0.001), and (2) metachronous presentation of the lung primary and brain metastasis versus synchronous presentation (17.6 months versus 9.5 months, P = 0.025). Survival comparisons which were not significantly different included single versus multiple metastases, complete versus incomplete resection, adenocarcinoma versus large or squamous or cell histology, supratentorial versus infratentorial location, solid versus cystic metastasis, and age < or = 60 years versus > 60 years. These results, when compared with the literature on brain metastases, suggest that aggressive resection of symptomatic metastases from lung cancer (even if multiple) can improve functional survival over conservative management, and that small, asymptomatic lesions are well-controlled by WBXRT. They also confirm the previous finding that surgical treatment of both the lung primary and the brain metastases may afford the greatest period of functional survival for these patients.