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Surgery on motor area metastasis

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Abstract

The role of surgery on central area metastasis remains unclear, and outcome data are still controversial. The aim of our study is to analyze the predictive value of clinical and surgical data on motor and functional outcome of patients, taking into account new emerging data on boundary irregularity of brain metastasis. We retrospectively analyzed 47 consecutive patients who underwent surgery assisted by neurophysiologic monitoring for a solitary metastasis in central area between 2010 and 2013. Inclusion criteria were as follows: good functional status (Karnofsky Performance Status (KPS) ≥70), controlled systemic disease, and absence of extra-cranial dissemination. At 1-month follow up, motor and functional outcomes were compared with preoperative clinical status, response to corticosteroids, extent of tumor resection, boundary irregularity, and size of tumor. Gross total resection was achieved in 93.6 % of cases. In preoperative symptomatic patients, motor outcome (according to Medical Research Council grading scale) improved in 55.5 % and worsened in 16.7 %, while functional outcome (according to KPS score) improved in 50 % and worsened in 14.2 % of cases. No worsening occurred in preoperative asymptomatic patients. Motor outcome resulted to be not correlated with preoperative deficits, tumor volume, or preoperative response to corticosteroid treatment. Remarkably, motor outcome and extent of surgical resection appeared strongly correlated with tumor boundary irregularity (p < 0.05). Surgery with neurophysiologic monitoring on motor area metastasis can improve functional and motor condition in selected patients. Tumor volume does not represent a limit in surgery. The high correlation between clinical outcome, resection rate, and tumor boundary irregularity strengthens a new belief on the infiltrative growing pattern of brain metastasis. Motor function was evaluated according to Medical Research Council grading scale (Ott et al. 2014) while functional status was assessed according to KPS score.

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Authors and Affiliations

  1. Department of Neurosurgery, Padua University Hospital, Azienda Ospedaliera di Padova, Via Giustiniani 2, 35128, Padova, Italy

    Marta Rossetto, Pietro Ciccarino & Alessandro Della Puppa

  2. Department of Oncology, IOV IRCCS Oncology Institute of Padua, Via Gattamelata 64, 35128, Padova, Italy

    Giuseppe Lombardi

  3. Neuroradiology Unit, Padua University Hospital, Via Giustiniani 2, Padua, 35128, Padova, Italy

    Giuseppe Rolma

  4. Department of Medicine (DIMED), Nuclear Medicine Service, University of Padua, Via Giustiniani 2, 35128, Padova, Italy

    Diego Cecchin

Authors
  1. Marta Rossetto
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  2. Pietro Ciccarino
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  3. Giuseppe Lombardi
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  4. Giuseppe Rolma
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  5. Diego Cecchin
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  6. Alessandro Della Puppa
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Correspondence to Alessandro Della Puppa.

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Comments

Yavor Enchev, Varna, Bulgaria

The authors retrospectively analyzed their own series of 47 consecutive patients with solitary metastatic lesions in motor area. The patients were included in the study based on strict enrollment criteria (KPS ≥70, absence of extracranial metastases and controlled systemic disease) and the tumours were resected with the assistance of neuronavigation and neurophysiologic monitoring. The motor and functional surgical outcome were evaluated and compared with the preoperative state. Based on their results, between their mostly confirmative data, the authors noted something very interesting, namely that the motor outcome and the extent of tumour resection strongly correlated with the so-called “tumour margins irregularity”. By my opinion, further studies focused on defining the criteria for tumour margins irregularity, evaluating its degree of expression and eventually its potential prognostic value for the extent of surgical resection and motor outcome, are recommended.

Fumio Yamaguchi, Tokyo, Japan

Rossetto et al. reported the utilization of brain mapping technique in the removal of metastatic brain tumors. As a nature of metastatic tumors, boundaries are macroscopically clear in most cases and easy to remove without damaging adjacent neural structure. However, as the authors discussed, it is difficult to remove the tumor in case of irregular tumor margin, resulting in subtotal removal or complete removal with postoperative neurological deteriorations in eloquent areas. If the invaded brain tissue includes any eloquent fibers, the decision of removal extent must be carefully made according to intraoperative brain mapping. Also, resection of the surrounding white matter is important to prevent local recurrence. Based on this concept, tractography integrated in neuronavigation system in conjunction with intraoperative brain mapping should be used routinely in case of tumors in eloquent brain even if tumor boundaries are clear. The resection of metastatic brain tumor may be considered simple and relatively easy surgery, however, the prevention of postoperative neurological deterioration should be set high value on for patients who have limited remaining days. From this point of view intraoperative mapping is very important and essential technique.

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Rossetto, M., Ciccarino, P., Lombardi, G. et al. Surgery on motor area metastasis. Neurosurg Rev 39, 71–78 (2016). https://doi.org/10.1007/s10143-015-0648-9

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  • DOI: https://doi.org/10.1007/s10143-015-0648-9

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