Operative Neurosurgery. 2026;31(2):270–284
Objective
To identify factors associated with early postoperative mortality and overall survival after surgical resection of melanoma brain metastases.
Methods
This retrospective single-center study included 103 patients who underwent resection as their initial treatment for melanoma brain metastases between 2009 and 2018. The primary outcomes were overall survival, 90-day mortality and development of leptomeningeal disease.
Main results
Nineteen patients (18%) died within 90 days of surgery. Elevated lactate dehydrogenase at diagnosis was independently associated with greater early mortality (OR 7.17).
Factors associated with lower 90-day mortality included:
- Postoperative Karnofsky Performance Status ≥80: OR 0.13.
- Brain metastasis already present at the diagnosis of stage IV disease: OR 0.11.
Better overall survival was associated with:
- Preoperative Karnofsky score ≥80: HR 0.46.
- Adjuvant stereotactic radiosurgery: HR 0.55.
- Surgical reduction of total intracranial tumor burden by ≥95.6%: HR 0.47.
- Synchronous diagnosis of brain metastasis and stage IV melanoma: HR 0.59.
No evaluated factor was significantly associated with subsequent leptomeningeal disease. PubMed abstract
Interpretation
Functional status remains central to surgical selection. The study also suggests that the value of surgery may depend not only on removing the symptomatic lesion but on achieving a major reduction in the patient’s total intracranial tumor burden.
The association between adjuvant stereotactic radiosurgery and longer survival supports a combined local-treatment strategy rather than surgery alone. Elevated LDH may help identify patients at particularly high risk of early postoperative death.
Limitations
The study was retrospective, conducted at a single tertiary cancer center and included patients treated between 2009 and 2018. Systemic melanoma therapy has evolved substantially since that period. The survival associations cannot establish that extensive resection or adjuvant radiosurgery directly caused better survival because healthier patients may have been more likely to receive these treatments.
Clinical takeaway
Surgery for melanoma brain metastases should be considered within a multimodal treatment strategy. Patients with good functional status are the most likely to benefit, while elevated LDH identifies a group with substantial early mortality risk. When safely achievable, a reduction of at least approximately 95% of total intracranial tumor burden may provide greater benefit than limited resection of the dominant lesion alone.