Surgical Resection for Brain Metastases

Abstract

Brain metastases are the most common intracranial neoplasms in adults, affecting 150,000–200,000 cancer patients per year in the United States [1, 2]. The most common primary sources of brain metastases are lung cancer, breast cancer, and melanoma, with melanoma most predisposed to metastasize to the brain [3]. Brain metastases traditionally result in poor outcomes and, unfortunately, often indicate the terminal stage of systemic cancer. Brain metastases pose a significant public health issue, as over one million people are diagnosed with cancer each year in the USA (www.cancer.gov/about-cancer/understanding/statistics). In addition to the obvious potential functional burden of brain metastasis to patients, the socioeconomic burden is also profound. A number of studies have demonstrated increased health care utilization and costs for patients after a diagnosis of brain metastasis. In a retrospective review of 132 patients with non-small cell lung cancer, prior to brain metastasis diagnosis, patients had a 6-month healthcare cost of $5983, which increased to over $22,000 after the diagnosis of brain metastasis. This same study found that patient resource utility also substantially increased, with a three-fold increase in outpatient visits and a six-fold increase in inpatient admission [4]. Furthermore, patients with brain metastases missed significantly more workdays, resulting in a salary loss of $2853 per patient over a 6-month period. Similarly, in breast cancer, relative to a matched control cohort, patients with brain metastasis had a mean overall healthcare cost of $99,899 over 12 months compared with $47,719 in patients without metastases [5]. Strategies for the management of brain metastases have developed tremendously over the past decade, including the use of immunotherapy [6, 7] and advancements in radiation techniques [8]. Surgical resection remains a cornerstone in the treatment of brain metastasis. This chapter will focus on the role of surgery in the treatment of patients with metastatic brain disease and discuss current perspectives in the surgical management of this complicated issue.