Surgery in brain metastasis management: Therapeutic, diagnostic, and strategic considerations

The incidence of brain metastases (BM) is increasing to date, mostly due to the actual improvement of cancer patient overall survival (OS) with the advent of targeted therapies. BM management has dramatically evolved over the last 15 years and uses varying strategies including more or less aggressive local treatments, sometimes combined with systemic therapies that led to an improvement of patient’s survival and quality of life. Surgical resection of BM has been shown to be an effective treatment improving overall survival compared to whole brain radiotherapy alone in patients with solitary brain metastasis. Brain metastases resection in patients with oligo metastatic disease especially for large symptomatic lesions with mass effect represent the standard of care. However, surgical resection alone is insufficient to provide a durable local control and recurrence in the surgical bed is common. Recent studies indicate local control could be improved through modern surgical techniques such as neuronavigation, brain mapping, and fluorescence guided surgery. Also, there is a growing body of evidence that molecular documentation of the brain metastatic disease could help to better define the systemic treatment strategy in these patients. Here, we reviewed evidence-based data available in the literature on the actual prognostic impact of surgery in BM patients and provided an overview of new surgical techniques and adjuncts that may improve surgical resection. Finally, we discussed the actual role of the neurosurgeon in the global treatment strategy and management in these BM patients.