Treatment selection and functional outcomes in motor cortex metastases.

BACKGROUND: Brain metastases are associated with a poor prognosis. While systemic therapy primarily determines overall survival, surgical cytoreduction may improve local disease control. Preserving neurological function and independence is particularly important in patients with limited life expectancy. However, surgery is often avoided for metastases located in eloquent brain regions. This study evaluates treatment selection and functional outcomes in patients with metastases involving the primary motor cortex. METHODS: We conducted a retrospective single-center analysis of patients treated for central motor eloquent brain metastases. Primary endpoints were motor function and KPS at discharge and at 6-month FU. Neurological change was categorized as improvement, stability, or deterioration in Medical Research Council (MRC) grade. Secondary variables included intracranial tumor burden, extracranial disease, prior systemic therapy, disease duration, which were used for risk stratification. Comparative analyses were performed using Wilcoxon rank-sum test, Fisher's exact test, multivariable logistic, and Firth regression. RESULTS: A total of 152 patients (79 male, 73 female; mean age 65.5 years) were eligible. Treatment comprised primary surgery in 109 patients, definitive stereotactic radiotherapy in 24, salvage surgery after radiotherapy in 17, and best supportive care in two. In single metastases with higher volume surgery was favored, whereas extracranial disease, prior systemic therapy, and longer disease duration were associated with allocation to radiotherapy. At discharge improvement rate was 13% (MSR) versus 25% (SRT) (p = 0.400), at 6-month FU improvement was 45% in the MSR and 9% in the SRT cohort (p = 0.063), while longitudinal analysis showed significant improvement in median MRC grade only in the surgery cohort. CONCLUSION: Surgery was not associated with inferior functional outcomes and even resulted in greater motor improvement at FU. These findings support surgery as a feasible treatment option, including for selected high-risk patients, while stereotactic radiotherapy seems to remain an important alternative for frailer patients with longer disease histories.