Clinical Scorecard: Risk Assessment in the Perioperative Period Following Brain Metastasis Resection: Development and Validation of the Dominant Lesion Surgery Score from a 20-Year Single-Center Study

At a Glance

Key Highlights

• Intracranial lesion count alone is insufficient for surgical decision-making; dominant lesion characteristics and clinical urgency are critical.
• Surgical resection benefits extend beyond solitary metastases to selected patients with dominant symptomatic lesions or life-threatening mass effect.
• Development and internal validation of the Dominant Lesion Surgery Score (DLSS) for perioperative risk stratification of early postoperative mortality.

Guideline-Based Recommendations

Diagnosis

• Histopathological confirmation of brain metastases following surgical resection is essential.
• Preoperative neuroimaging to assess intracranial lesion number and distribution.

Management

• Surgical resection considered for dominant symptomatic lesions, life-threatening mass effect, or diagnostic clarification within a multidisciplinary treatment plan.
• Integration of surgery with stereotactic radiosurgery and systemic therapies tailored to tumor biology and patient status.
• Extent of resection classified as gross total resection (GTR) or subtotal resection (STR) based on postoperative imaging.

Monitoring & Follow-up

• Early postoperative imaging to evaluate extent of resection and residual disease.
• Multidisciplinary tumor board review for treatment planning and follow-up.
• Survival and recurrence monitoring to inform ongoing management.

Risks

• Early postoperative mortality risk stratified using the Dominant Lesion Surgery Score (DLSS).
• Consideration of tumor biology, operative completeness, and systemic disease burden in perioperative risk assessment.

Patient & Prescribing Data

Adults undergoing dominant lesion brain metastasis resection in a tertiary neurosurgical center.

Surgical selection should be individualized, incorporating neurological status, systemic disease, and expected local control; DLSS aids perioperative risk stratification.

Clinical Best Practices

• Use multidisciplinary evaluation integrating neurosurgery, radiation oncology, and medical oncology for treatment planning.
• Prioritize surgical resection for dominant lesions causing neurological compromise or requiring tissue diagnosis.
• Employ postoperative cavity-directed irradiation and systemic therapies with CNS activity as part of multimodal management.
• Apply the Dominant Lesion Surgery Score to assess perioperative mortality risk and guide clinical decision-making.
• Recognize limitations of lesion count alone; incorporate tumor biology and extent of resection in prognostication.

References

• Multidisciplinary guidelines on brain metastasis management
• Randomized studies on surgery plus radiotherapy vs radiotherapy alone
• Diagnosis-specific graded prognostic assessments for brain metastases
• Advances in stereotactic radiosurgery and postoperative radiation