Improved survival with surgical treatment of both primary lung cancer and brain metastases

Survival benefits of primary tumor surgery for synchronous brain metastases: A SEER-based population study with propensity-matched comparative analysis

BACKGROUND

Evidence about the prognostic value of primary tumor surgery (PTS) in patients with brain metastatic malignancies is ambiguous and controversial. This study assessed the survival benefits of primary tumor surgery in patients with brain metastases (BMs).

METHODS

Adults patients with BMs that originated from lung, breast, kidney, skin, colon, and liver diagnosed between 2010 and 2018 were derived from the Surveillance, Epidemiology, and End Results database (SEER). Propensity score matching (PSM) was used to balance the bias between patients with or without PTS. Then the prognostic value of PTS was estimated by Kaplan-Meier analysis and Cox proportional hazard regression models.

RESULTS

A total of 32,760 patients with BMs secondary to non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC), breast cancer, renal cancer, melanoma, colorectal cancer, and liver cancer were identified from the database. After PSM at 1:1 ratio, PTS appeared to significantly prolong cause-specific survival (CSS) time for patients with BMs secondary to NSCLC, breast cancer, renal cancer, and colorectal cancer (hazard ratio [HR] = 0.60 [0.53-0.68], 0.56 [0.43-0.73], 0.47 [0.37-0.60], and 0.59 [0.37-0.95], respectively, all p < 0.05). Patients with earlier T and N classifications, no extracranial metastasis, and cancer-specific subtypes (adenocarcinoma in NSCLC, hormone receptor-negative breast cancer) may derive more survival benefits from PTS when suffering from BMs.

CONCLUSION

This population-based study supported PTS could provide survival benefits for patients with BMs secondary to NSCLC, breast cancer, renal cancer, and colorectal cancer. More emphasis should be put on PTS of selected patients with BMs.

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.

The role of adjuvant radiation and multiple resection within the surgical management of brain metastases

Cerebral metastases occur in 25% to 35% of all cancer patients. The advances in systemic and topical treatment as well as the rising incidence of lung cancer and melanomas are associated with an increasing incidence of cerebral metastases. More than 20,000 patients die every year in the Federal Republic of Germany of this disease. This retrospective analysis covers 145 patients who underwent surgery. Survival analysis of different subgroups was performed. The patients were grouped according to their clinical status and the different therapeutical procedures which were performed. Group A, consisting of all those patients where a gross total resection could be performed and where no systemic disease was apparent at the time of craniotomy showed the best results, having the highest portion of long term survivors. Group B, consisting of those patients who underwent a subtotal resection and who had no systemic disease at the time of craniotomy, had a worse outcome. Group C patients (gross total resection and systemic disease) as well as Group D (subtotal resection and systemic disease) presented the poorest results with respect to survival. A benefit was mediated by adjuvant radiation as well as multiple resections. Surgery is the method of choice for the treatment of a single metastasis. Advances in microsurgery nowadays sometimes justify even the removal of multiple metastases, depending on their location, on the general condition of the patient and on prognosis.