Gamma Knife radiosurgery to the surgical cavity following resection of brain metastases

Clinical article

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This study evaluated the efficacy of postoperative Gamma Knife surgery (GKS) to the tumor cavity following gross-total resection of a brain metastasis.


A retrospective review was conducted of 700 patients who were treated for brain metastases using GKS. Forty-seven patients with pathologically confirmed metastatic disease underwent GKS to the postoperative resection cavity following gross-total resection of the tumor. Patients who underwent subtotal resection or who had visible tumor in the resection cavity on the postresection neuroimaging study (either CT or MR imaging with and without contrast administration) were excluded. Radiographic and clinical follow-up was assessed using clinic visits and MR imaging. The radiographic end point was defined as tumor growth control (no tumor growth regarding the resection cavity, and stable or decreasing tumor size for the other metastatic targets). Clinical end points were defined as functional status (assessed prospectively using the Karnofsky Performance Scale) and survival. Primary tumor pathology was consistent with lung cancer in 19 cases (40%), melanoma in 10 cases (21%), renal cell carcinoma in 7 cases (15%), breast cancer in 7 cases (15%), and gastrointestinal malignancies in 4 cases (9%). The mean duration between resection and radiosurgery was 15 days (range 2–115 days). The mean volume of the treated cavity was 10.5 cm3 (range 1.75–35.45 cm3), and the mean dose to the cavity margin was 19 Gy. In addition to the resection cavity, 34 patients (72%) underwent GKS for 116 synchronous metastases observed at the time of the initial radiosurgery.


The mean radiographic follow-up duration was 14 months (median 10 months, range 4–37 months). Local tumor control at the site of the surgical cavity was achieved in 44 patients (94%), and tumor recurrence at the surgical site was statistically related to the volume of the surgical cavity (p = 0.04). During follow-up, 34 patients (72%) underwent additional radiosurgery for 140 new (metachronous) metastases. At the most recent follow-up evaluation, 11 patients (23%) were alive, whereas 36 patients had died (mean duration until death 12 months, median 10 months). Patients who showed good systemic control of their primary tumor tended to have longer survival durations than those who did not (p = 0.004). At the last clinical follow-up evaluation, the mean Karnofsky Performance Scale score for the overall group was 78 (median 80, range 40–100).


Radiosurgery appears to be effective in terms of providing local tumor control at the resection cavity following resection of a brain metastasis, and in the treatment of synchronous and metachronous tumors. These data suggest that radiosurgery can be used to prevent recurrence following gross-total resection of a brain metastasis.

Abbreviations used in this paper: GKS = Gamma Knife surgery; KPS = Karnofsky Performance Scale; WBRT = whole brain radiation therapy.

Article Information

Address correspondence to: Jason P. Sheehan, M.D., Ph.D., Department of Neurological Surgery, University of Virginia Health Sciences Center, Box 800212, Charlottesville, Virginia 22908. email:

Please include this information when citing this paper: published online April 10, 2009; DOI: 10.3171/2008.11.JNS08818.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Summary of patients and treatments. Forty-seven patients received GKS to the resection cavity. Three patients received WBRT prior to radiosurgery, whereas 34 patients had concomitant radiosurgery for a synchronous metastasis. Thirteen patients showed no radiographically visible tumor at treatment. Three of these patients underwent upfront WBRT. All 10 of the remaining patients required treatment for metachronous disease (5 underwent radiosurgery and 5 underwent WBRT).

  • View in gallery

    Graphs of the 116 synchronous tumors (left) and 140 metachronous tumors (right) grouped according to volume and primary pathology (tumor type). Left: Tumor size was stable or decreased in 94 cases (81%, black circles), with 16 tumors not visible on follow-up MR imaging (open circles). The 22 tumors that appeared to grow in size (triangles) occurred more commonly in melanoma and renal cell carcinoma. Right: Tumor size was stable or decreased in 105 cases (74%, black circles), with 43 tumors not visible on follow-up MR imaging (open circles). Thirty-five tumors appeared to grow in size (triangles). GI = gastrointestinal.

  • View in gallery

    Graph of Kaplan-Meier curves showing the time to treatment failure at the resection cavity (solid line) versus time to tumor growth for the 57 of 257 tumors (22 synchronous and 35 metachronous metastases) that did not respond to radiosurgery (dotted line).

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    Graph showing the number of patients with systemic disease control and progressive disease control correlated with survival. In the 47 patients treated, those with systemic disease control had the highest correlation with survival (p = 0.03, Student t-test). Ten (83%) of 12 patients with systemic control were alive at the most recent follow-up evaluation, whereas 34 (97%) of 35 patients with progressive systemic disease were dead.

  • View in gallery

    Graph of Kaplan-Meier curves depicting survival in patients who received postoperative WBRT (solid line) compared with patients who did not (dotted line). No statistically significant difference in survival was observed.

  • View in gallery

    Graph depicting the relationship between KPS score and tumor burden. Although patients who received WBRT had lower KPS scores on follow-up, this result likely reflects the fact that these patients had a higher tumor load.


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