Surgical treatment of cerebellar metastases in elderly patients: A threshold that moves forward?

Abstract

The impact of surgery for cerebellar brain metastases in elderly population has been the object of limited studies in literature. Given the increasing burden of their chronic illnesses, the decision to recommend surgery remains difficult. All patients aged ≥65 years, who underwent surgical resection of a cerebellar brain metastasis from May 2000 and May 2021 at IRCCS National Cancer Institute "Regina Elena", were analyzed. The study cohort includes 48 patients with a mean age of 70.8 years. 7 patients belonged to the II Class according to the RPA classification, 41 to the III Class; the median GPA classification was 1.5. Median pre-operative and post-operative KPS was 60. Median Charlson Comorbidity Index (CCI) was 11; median 5-variable modified Frailty Index was 2. Overall, 14 patients (29%) presented perioperative neurologic and systemic complications. 34 patients (71%) were able to perform adjuvant therapies as RT and/or CHT after surgery. A higher CCI predicted complications occurrence (p = 0.044), while significant factors for a post-operative KPS ≥70, were i) hemispheric location of the metastasis, ii) higher pre-operative KPS, iii) RPA II classification. Median Overall Survival was 7 months. A post-operative KPS <70 (p = 0.004) and a short time interval between diagnosis of the primary tumor and cerebellar metastasis appearance, were predictive for a worse outcome (p = 0.012). Our study suggests that selected elderly patients with cerebellar metastases may benefit from microsurgery to continue their adjuvant therapies, although a high complications rate should be taken in account.

Keywords: Cerebellar metastases; Elderly patients; Frailty index; Perioperative outcomes; Postoperative complications.

Fig. 1

a: 3D reconstruction and axial, sagittal and coronal T1 weighted MR images with Gadolinium of a large hemispheric right cerebellar metastasis in an 80-year-old female affected by ovarian cancer (RPA Class III, GPA score 1). b: post-operative axial CT scan with contrast showing an apparent complete removal of the lesion. c: axial and sagittal T1 weighted MR images with Gadolinium after SRS treatment, 4 weeks after surgery demonstrating local disease control. The patient died 8 months after surgery due to progressive systemic disease.

Fig. 2

a: axial and sagittal T1 weighted MR images with Gadolinium of a hemispheric right cerebellar metastasis in an 82-year-old female affected by breast cancer (RPA Class III, GPA score 2). b: intraoperative image during tumor removal. c: post-operative T1 weighted MR images with Gadolinium, demonstrating complete removal of the lesion. d: post-operative T1 weighted MR images at seven months after surgery showing a significant recurrent lesion with involvement of the cerebellar-pontine angle. The patient died 8 months after surgery due to local disease progression.

Fig. 3

a: preoperative T1 with Gadolinium and T2-weighted MR images showing a paramedian cerebellar metastasis in a 77-year-old male affected by melanoma (RPA class III, GPA score 1) associated to progressive consciousness deterioration. b: axial CT scan showing a post-operative hematoma in the surgical bed causing coma. c: intraoperative view during hematoma removal. d: post-operative CT scan after removal of the hematoma and external ventricular catheter positioning. The patient recovered only partially from his comatose state and died 15 days after surgery, due to nosocomial lung infection.