Re-resection of brain metastases – outcomes of an institutional cohort study and literature review

Background: Surgically accessible brain metastases are treated through microsurgical removal followed by radiation therapy, resulting in improved progression-free and overall survival. Some patients experience recurrence, prompting the need for effective management strategies. Despite the prevalence of recurrence, there remains a gap in the literature regarding the outcomes of patients undergoing re-resection of brain metastases. Objectives: This study aims to comprehensively characterize clinical, radiological, histopathological, and treatment-related aspects, along with outcomes, for patients undergoing re-resection of locally and distantly recurrent brain metastases. Methods: We conducted a single-center retrospective cohort study, including patients who underwent secondary brain metastasis resection following prior primary brain metastasis resection and irradiation. Results: Among 60 patients, 41 (68.3%) had local recurrences, and 19 (31.7%) had distant recurrences. Median intracranial progression-free survival was 7.7 months [95% CI: 6.5–11.2], time to re-resection was 11.6 months [95% CI: 9.1–15.3], and overall survival was 30.8 months [95% CI: 20.4–49.5]. Non-small cell lung cancer (NSCLC) was the most common primary tumor. Post-initial resection treatments included radiation alone (31.7%), radiation plus chemotherapy (25.0%), radiation plus targeted therapy (15.0%), and radiation plus immunotherapy (28.3%). Cavity irradiation was performed in 46 patients (76.7%) and whole brain radiation in 14 (23.3%). Post-re-resection treatments varied: 21 patients (35.0%) received best supportive care, 15 (25.0%) radiation only, 12 (20.0%) systemic therapy only, and 12 (20.0%) both radiation and systemic therapy. Independent risk factors for shorter overall survival included non-breast cancer histology, pre-re-resection tumor volume > 9 mL, pre-re-resection Karnofsky Performance Status ≤ 60%, and presence of vital tumor cells at re-resection. Conclusion: Brain metastasis resection of local and distant recurrences is feasible and a treatment option for selected patients with good clinical performance status. This study underscores the potential role of re-resection in brain metastasis. Further research to improve patient selection and treatment algorithms is warranted.