The role of neurosurgery for brain metastases between 2012 and 2022: Results of the multicenter <i>SUBAROMA</i> study

Abstract Background We analyzed the role of neurosurgery combined with postoperative treatment according to current guidelines in a real-world cohort of patients with brain metastasis (BM) over an 11-year period to (re-)evaluate predictors of local intracranial recurrence (LR) and overall survival (OS). Methods We conducted the SUBARoMA study (Surgery for brain metastases: a retrospective multicenter analysis), including patients undergoing surgery as initial treatment for their BM. Significant factors impacting LR and OS were analyzed by univariate (Kaplan-Meier) and multivariate (Cox regression) methods. Results We included 2,751 patients. Resection significantly improved patients’ postoperative Karnofsky Performance Score (KPS, P < .001). Gross-total resection (rate 73%) increased by fluorescence guidance but exerted no effect on morbidity (rate 20.4%) (P < .001, respectively). The risk of LR was 23.5% at 1 year and 40.4% at 4 years. Postoperative systemic- (P = .021) and radiotherapy (P < .001) had an independent impact on LR. Mean/median OS was 15.0/7.5 months. The strongest independent predictors of OS were age, number of BM, active extracranial tumor, as well as improvement of postoperative KPS, radiation-, and systemic therapy including targeted and/or immunotherapy (P < .001, respectively). Over the 11-year period, application of whole-brain radiotherapy decreased in favor of focal radiation, and administration of systemic treatment, particularly targeted and/or immunotherapies, increased. By combining surgery, postoperative radiation, and systemic therapy, 5-year survival rates of >30% were achieved. Conclusion The SUBARoMA study confirms the crucial role of neurosurgery for patients with BM by improving their KPS to enable guideline-conforming postoperative treatment and underscores meticulous patient selection for surgical management of BM.