Surgical Management of Recurrent Brain Metastases: A Review

As survival for cancer patients improves, the incidence of brain metastases has risen. This is likely due to improved systemic disease control, increased diligence in surveillance imaging in high-risk pathologies, improved neuro-imaging techniques and increased systemic screening for clinical trial enrollment. While there are well-established treatments for brain metastases, many patients will experience recurrence after definitive treatment. The management of these recurrent lesions is not well established and often varies on a per-patient basis, owing to the clinical complexity and variety of these patients. Patients with recurrent brain metastases have surgical procedural options to achieve local tumor control, including laser interstitial thermal therapy (LITT) repeat open surgical resection with or without placement of intracavity brachytherapy. Repeat resection can offer rapid improvement in neurological symptoms, performance status, and potentially survival. LITT is less invasive than a standard craniotomy but offers a chance at directed local treatment while still obtaining tissue for diagnostic purposes and achieving acceptable survival outcomes. Further study is needed to determine the role of LITT for recurrent brain metastases, but it is a useful tool, particularly for patients with deep-seated lesions who may not tolerate a large surgery. Intracavitary brachytherapy allows for the immediate delivery of highly conformal radiation to the surgical bed with excellent local control and low rates of radiation necrosis, even in previously irradiated patients. The decision regarding which of the above to employ for recurrent brain metastases will vary on a case-by-case basis, and further studies are needed to standardize their use for this growing problem.