J Neurol Surg A Cent Eur Neurosurg 2019; 80(03): 198-204
DOI: 10.1055/s-0038-1676575
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Surgical Management of Deep-Seated Metastatic Brain Tumors Using Minimally Invasive Approaches

Kelly Gassie
1   Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, United States
Keila Alvarado-Estrada
1   Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, United States
Perry Bechtle
1   Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, United States
Kaisorn L. Chaichana
1   Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, United States
› Author Affiliations
Further Information

Publication History

25 June 2018

28 August 2018

Publication Date:
20 March 2019 (online)


Background and Study Aims/Objective Metastatic brain tumors are the most common type of adult brain tumors. Treatment involves surgery and/or radiation therapy. Surgery is typically reserved for patients with good neurologic function, solitary and accessible lesions, symptomatic lesions, and/or those with good systemic control of their primary cancer. Deep-seated lesions, however, are typically treated with palliative options including radiation and medical therapies. We summarize our personal experience with minimally invasive surgical approaches for these deep-seated metastatic brain tumors using tubular retractors with exoscopic visualization.

Material and Methods Patients with deep-seated metastatic brain tumors who were operated on from January 2016 to December 2017 by the senior author were collected prospectively. “Deep seated” was defined as any subcortical location below the deepest adjacent sulcus in close proximity to the basal ganglia and/or thalamus. “Minimally invasive” was defined as the use of tubular retractors with exoscopic visualization.

Results A total of 15 consecutive patients with an average ± standard deviation age of 63 ± 12 years underwent surgical resection of a deep-seated metastasis. The tumor was located in the centrum semiovale in seven (47%) (3 corticospinal tract, 2 superior longitudinal fasciculus, 1 visual tract, 1 inferior frontal occipital fasciculus), basal ganglia in three (20%), thalamus in two (13%), and cerebellum in three (20%). Median percentage resection was 100% (interquartile range:100–100%), and, following surgery, seven (47%), seven (47%), and one (7%) had an improved, stable, and worse Karnofsky Performance Score, respectively. No patients had notable local complications including stroke, infection, hemorrhage, and/or seizure. All patients underwent postoperative stereotactic radiosurgery.

Conclusion This minimally invasive approach can be used to achieve extensive resection with minimal morbidity for arguably the highest risk metastatic brain tumors.

  • References

  • 1 D'Andrea G, Palombi L, Minniti G, Pesce A, Marchetti P. Brain metastases: surgical treatment and overall survival. World Neurosurg 2017; 97: 169-177
  • 2 Chaichana KL, Acharya S, Flores M. , et al. Identifying better surgical candidates among recursive partitioning analysis class 2 patients who underwent surgery for intracranial metastases. World Neurosurg 2014; 82 (1–2): e267-275
  • 3 Chaichana KL, Gadkaree S, Rao K. , et al. Patients undergoing surgery of intracranial metastases have different outcomes based on their primary pathology. Neurol Res 2013; 35 (10) 1059-1069
  • 4 Chaichana KL, Rao K, Gadkaree S. , et al. Factors associated with survival and recurrence for patients undergoing surgery of cerebellar metastases. Neurol Res 2014; 36 (01) 13-25
  • 5 Wu A, Weingart JD, Gallia GL. , et al. Risk factors for preoperative seizures and loss of seizure control in patients undergoing surgery for metastatic brain tumors. World Neurosurg 2017; 104: 120-128
  • 6 Kalkanis SN, Kondziolka D, Gaspar LE. , et al. The role of surgical resection in the management of newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline. J Neurooncol 2010; 96 (01) 33-43
  • 7 Kondziolka D, Kano H, Harrison GL. , et al. Stereotactic radiosurgery as primary and salvage treatment for brain metastases from breast cancer. Clinical article. J Neurosurg 2011; 114 (03) 792-800
  • 8 Bakhsheshian J, Strickland BA, Jackson C. , et al. Multicenter investigation of channel-based subcortical trans-sulcal exoscopic resection of metastatic brain tumors: a retrospective case series. Oper Neurosurg (Hagerstown) 2018; April 18 (Epub ahead of print)
  • 9 Chaichana KL, Vivas-Buitrago T, Jackson C. , et al. The radiographic effects of surgical approach and use of retractors on the brain after anterior cranial fossa meningioma resection. World Neurosurg 2018; 112: e505-e513
  • 10 Gassie K, Wijesekera O, Chaichana KL. Minimally invasive tubular retractor-assisted biopsy and resection of subcortical intra-axial gliomas and other neoplasms. J Neurosurg Sci 2018
  • 11 Iyer R, Chaichana KL. Minimally invasive resection of deep-seated high-grade gliomas using tubular retractors and exoscopic visualization. J Neurol Surg A Cent Eur Neurosurg 2018; 79 (04) 330-336
  • 12 Jackson C, Gallia GL, Chaichana KL. Minimally invasive biopsies of deep-seated brain lesions using tubular retractors under exoscopic visualization. J Neurol Surg A Cent Eur Neurosurg 2017; 78 (06) 588-594
  • 13 Kelly PJ, Goerss SJ, Kall BA. The stereotaxic retractor in computer-assisted stereotaxic microsurgery. Technical note. J Neurosurg 1988; 69 (02) 301-306
  • 14 Labib MA, Shah M, Kassam AB. , et al. The safety and feasibility of image-guided BrainPath-mediated transsulcul hematoma evacuation: a multicenter study. Neurosurgery 2017; 80 (04) 515-524
  • 15 Day JD. Transsulcal parafascicular surgery using brain path® for subcortical lesions. Neurosurgery 2017; 64 (CN_Suppl_1): 151-156
  • 16 Hong CS, Prevedello DM, Elder JB. Comparison of endoscope- versus microscope-assisted resection of deep-seated intracranial lesions using a minimally invasive port retractor system. J Neurosurg 2016; 124 (03) 799-810
  • 17 Raza SM, Recinos PF, Avendano J, Adams H, Jallo GI, Quinones-Hinojosa A. Minimally invasive trans-portal resection of deep intracranial lesions. Minim Invasive Neurosurg 2011; 54 (01) 5-11
  • 18 Recinos PF, Raza SM, Jallo GI, Recinos VR. Use of a minimally invasive tubular retraction system for deep-seated tumors in pediatric patients. J Neurosurg Pediatr 2011; 7 (05) 516-521
  • 19 Eliyas JK, Glynn R, Kulwin CG. , et al. Minimally invasive transsulcal resection of intraventricular and periventricular lesions through a tubular retractor system: multicentric experience and results. World Neurosurg 2016; 90: 556-564
  • 20 Kelly PJ, Kall BA, Goerss SJ. Computer-interactive stereotactic resection of deep-seated and centrally located intraaxial brain lesions. Appl Neurophysiol 1987; 50 (1-6): 107-113
  • 21 Kelly PJ. Stereotactic biopsy and resection of thalamic astrocytomas. Neurosurgery 1989; 25 (02) 185-194 ; discussion 194–195
  • 22 Bander ED, Jones SH, Kovanlikaya I, Schwartz TH. Utility of tubular retractors to minimize surgical brain injury in the removal of deep intraparenchymal lesions: a quantitative analysis of FLAIR hyperintensity and apparent diffusion coefficient maps. J Neurosurg 2016; 124 (04) 1053-1060