title: Results of surgical resection for progression of brain metastases previously treated by gamma knife radiosurgery.
abstract: OBJECTIVE
  To determine treatment outcome after surgical resection for progressive brain metastases after gamma knife radiosurgery (GKR) and to explore the role of dynamic contrast agent-enhanced perfusion magnetic resonance imaging (MRI) and proton spectroscopic MRI studies (MRS/P) in predicting pathological findings.
  
  
  METHODS
  Between 1997 and 2002, 32 patients underwent surgical resection for suspected progression of brain metastases from a cohort of 245 patients with brain metastases treated with GKR. Postradiosurgery MRI surveillance was performed at 6 and 12 weeks, and then every 12 weeks after GKR. In some cases, additional MRI scanning with spectroscopy or perfusion (MRS/P) was used to aid differentiation of radiation change from tumor progression. The decision to perform neurosurgical resection was based on MRI or clinical evidence of lesion progression among patients with a Karnofsky performance score of 60 or more and absent or stable systemic disease.
  
  
  RESULTS
  Thirteen percent (32 out of 245) of patients and 6% (38 out of 611) of lesions required surgical resection after GKR. The median time from GKR to surgical resection was 8.6 months (range, 1.7-27.1 mo). The 6-, 12-, and 24-month actuarial survival from time of GKR was 97, 78, and 47% for the resected patients and 65, 40, and 19% for the nonresected patients (P < 0.0001). The two-year survival rate of patients requiring two resections after GKR was 100% compared with 39% for patients undergoing one resection (P = 0.02). The median survival of resected patients was 27.2 months (range, 7.0-72.5 mo) from the diagnosis of brain metastases, 19.9 months (range, 5.0-60.7 mo) from GKR, and 8.9 months (range, 0.2-53.1 mo) from surgical resection. Tumor was found in 90% of resected specimens and necrosis alone in 10%. MRS/P studies were performed in 15 resected patients. Overall, MRS/P predicted tumor in 11 lesions, confirmed pathologically in nine lesions, and necrosis alone was found in two. The MRS/P predicted necrosis alone in three, whereas pathology revealed viable tumor in two and necrosis in one lesion.
  
  
  CONCLUSIONS
  Surgical intervention of progressive brain metastases after GKR in selected patients leads to a meaningful improvement in survival rates. Further studies are necessary to determine the role of MRS/P in the postradiosurgery surveillance of brain metastases.
authors.affiliation: Department of Radiation Oncology, Boston University School of Medicine, Boston, Massachusetts 02118, USA. mttruong@partners.org
authors.forename: Minh T
authors.initials: MT
authors.lastname: Truong
authors.forename: Eric G
authors.initials: EG
authors.lastname: St Clair
authors.forename: Bernadine R
authors.initials: BR
authors.lastname: Donahue
authors.forename: Stephen C
authors.initials: SC
authors.lastname: Rush
authors.forename: Douglas C
authors.initials: DC
authors.lastname: Miller
authors.forename: Silvia C
authors.initials: SC
authors.lastname: Formenti
authors.forename: Edmond A
authors.initials: EA
authors.lastname: Knopp
authors.forename: Kerry
authors.initials: K
authors.lastname: Han
authors.forename: John G
authors.initials: JG
authors.lastname: Golfinos
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001932:Brain Neoplasms / Q000175:diagnosis / Q000473:pathology / Q000556:secondary* / Q000601:surgery*; D015331:Cohort Studies; D018450:Disease Progression; D006801:Humans; D008279:Magnetic Resonance Imaging; D009682:Magnetic Resonance Spectroscopy; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000009:adverse effects; D011379:Prognosis; D016634:Radiosurgery; D012086:Reoperation; D012189:Retrospective Studies; D016019:Survival Analysis; D013997:Time Factors