Impact of 2-staged stereotactic radiosurgery for treatment of brain metastases ≥ 2 cm

View More View Less
  • 1 Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute,
  • 2 Department of Neurosurgery, Neurological Institute,
  • 3 Quantitative Health Sciences, Taussig Cancer Institute, and
  • 5 Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; and
  • 4 Department of Neurosurgery, Alexandria University, Alexandria, Egypt
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

OBJECTIVE

Stereotactic radiosurgery (SRS) is the primary modality for treating brain metastases. However, effective radiosurgical control of brain metastases ≥ 2 cm in maximum diameter remains challenging and is associated with suboptimal local control (LC) rates of 37%–62% and an increased risk of treatment-related toxicity. To enhance LC while limiting adverse effects (AEs) of radiation in these patients, a dose-dense treatment regimen using 2-staged SRS (2-SSRS) was used. The objective of this study was to evaluate the efficacy and toxicity of this treatment strategy.

METHODS

Fifty-four patients (with 63 brain metastases ≥ 2 cm) treated with 2-SSRS were evaluated as part of an institutional review board–approved retrospective review. Volumetric measurements at first-stage stereotactic radiosurgery (first SSRS) and second-stage SRS (second SSRS) treatments and on follow-up imaging studies were determined. In addition to patient demographic data and tumor characteristics, the study evaluated 3 primary outcomes: 1) response at first follow-up MRI, 2) time to local progression (TTP), and 3) overall survival (OS) with 2-SSRS. Response was analyzed using methods for binary data, TTP was analyzed using competing-risks methods to account for patients who died without disease progression, and OS was analyzed using conventional time-to-event methods. When needed, analyses accounted for multiple lesions in the same patient.

RESULTS

Among 54 patients, 46 (85%) had 1 brain metastasis treated with 2-SSRS, 7 patients (13%) had 2 brain metastases concurrently treated with 2-SSRS, and 1 patient underwent 2-SSRS for 3 concurrent brain metastases ≥ 2 cm. The median age was 63 years (range 23–83 years), 23 patients (43%) had non–small cell lung cancer, and 14 patients (26%) had radioresistant tumors (renal or melanoma). The median doses at first and second SSRS were 15 Gy (range 12–18 Gy) and 15 Gy (range 12–15 Gy), respectively. The median duration between stages was 34 days, and median tumor volumes at the first and second SSRS were 10.5 cm3 (range 2.4–31.3 cm3) and 7.0 cm3 (range 1.0–29.7 cm3). Three-month follow-up imaging results were available for 43 lesions; the median volume was 4.0 cm3 (range 0.1–23.1 cm3). The median change in volume compared with baseline was a decrease of 54.9% (range −98.2% to 66.1%; p < 0.001). Overall, 9 lesions (14.3%) demonstrated local progression, with a median of 5.2 months (range 1.3–7.4 months), and 7 (11.1%) demonstrated AEs (6.4% Grade 1 and 2 toxicity; 4.8% Grade 3). The estimated cumulative incidence of local progression at 6 months was 12% ± 4%, corresponding to an LC rate of 88%. Shorter TTP was associated with greater tumor volume at baseline (p = 0.01) and smaller absolute (p = 0.006) and relative (p = 0.05) decreases in tumor volume from baseline to second SSRS. Estimated OS rates at 6 and 12 months were 65% ± 7% and 49% ± 8%, respectively.

CONCLUSIONS

2-SSRS is an effective treatment modality that resulted in significant reduction of brain metastases ≥ 2 cm, with excellent 3-month (95%) and 6-month (88%) LC rates and an overall AE rate of 11%. Prospective studies with larger cohorts and longer follow-up are necessary to assess the durability and toxicities of 2-SSRS.

ABBREVIATIONS 2-SSRS = 2-staged stereotactic radiosurgery; AE = adverse effect; BED = biologically effective dose; CTCAE = Common Terminology Criteria for Adverse Events; FSRS = fractionated stereotactic radiosurgery; GPA = graded prognostic assessment; hypo-FSRS = hypofractionated stereotactic radiosurgery; KPS = Karnofsky Performance Scale; LBM = large brain metastases; LC = local control; MLD = maximum linear dimension; OS = overall survival; RN = radiation necrosis; RPA = recursive partitioning analysis; SRS = stereotactic radiosurgery; SSRS = staged stereotactic radiosurgery; TTP = time to local progression; WBRT = whole-brain radiation therapy.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Correspondence Gene H. Barnett, The Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic Neurological and Cancer Institutes, Cleveland Clinic, S73, 9500 Euclid Ave., Cleveland, OH 44195. email: barnetg@ccf.org.

INCLUDE WHEN CITING Published online September 22, 2017; DOI: 10.3171/2017.3.JNS162532.

Disclosures Dr. Ahluwalia is a consultant for Monteris Medical, Bristol-Myers Squibb, Astra Zeneca, Elsevier, and Elekta. Dr. Ahluwalia received an honorarium from Prime Oncology. Dr. Suh is a consultant for and has received research support from Varian Medical Systems. Dr. Suh is also a consultant for Philips and has received reimbursement of travel and lodging expenses from Elekta.

  • 1

    Andrews DW, Scott CB, Sperduto PW, Flanders AE, Gaspar LE, Schell MC, : Whole brain radiation therapy with or without stereotactic radiosurgery boost for patients with one to three brain metastases: phase III results of the RTOG 9508 randomised trial. Lancet 363:16651672, 2004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Aoyama H, Shirato H, Tago M, Nakagawa K, Toyoda T, Hatano K, : Stereotactic radiosurgery plus whole-brain radiation therapy vs stereotactic radiosurgery alone for treatment of brain metastases: a randomized controlled trial. JAMA 295:24832491, 2006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Aoyama H, Tago M, Kato N, Toyoda T, Kenjyo M, Hirota S, : Neurocognitive function of patients with brain metastasis who received either whole brain radiotherapy plus stereotactic radiosurgery or radiosurgery alone. Int J Radiat Oncol Biol Phys 68:13881395, 2007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Arvold ND, Lee EQ, Mehta MP, Margolin K, Alexander BM, Lin NU, : Updates in the management of brain metastases. Neuro Oncol 18:10431065, 2016

  • 5

    Balagamwala EH, Chao ST, Suh JH: Principles of radiobiology of stereotactic radiosurgery and clinical applications in the central nervous system. Technol Cancer Res Treat 11:313, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Baschnagel AM, Meyer KD, Chen PY, Krauss DJ, Olson RE, Pieper DR, : Tumor volume as a predictor of survival and local control in patients with brain metastases treated with Gamma Knife surgery. J Neurosurg 119:11391144, 2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Bender ET: Brain necrosis after fractionated radiation therapy: is the halftime for repair longer than we thought? Med Phys 39:70557061, 2012

  • 8

    Blonigen BJ, Steinmetz RD, Levin L, Lamba MA, Warnick RE, Breneman JC: Irradiated volume as a predictor of brain radionecrosis after linear accelerator stereotactic radiosurgery. Int J Radiat Oncol Biol Phys 77:9961001, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Brown PD, Jaeckle K, Ballman KV, Farace E, Cerhan JH, Anderson SK, : Effect of radiosurgery alone vs radiosurgery with whole brain radiation therapy on cognitive function in patients with 1 to 3 brain metastases: a randomized clinical trial. JAMA 316:401409, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Chang EL, Hassenbusch SJ III, Shiu AS, Lang FF, Allen PK, Sawaya R, : The role of tumor size in the radiosurgical management of patients with ambiguous brain metastases. Neurosurgery 53:272281, 2003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Chang EL, Wefel JS, Hess KR, Allen PK, Lang FF, Kornguth DG, : Neurocognition in patients with brain metastases treated with radiosurgery or radiosurgery plus whole-brain irradiation: a randomised controlled trial. Lancet Oncol 10:10371044, 2009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Chao ST, Barnett GH, Vogelbaum MA, Angelov L, Weil RJ, Neyman G, : Salvage stereotactic radiosurgery effectively treats recurrences from whole-brain radiation therapy. Cancer 113:21982204, 2008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Crossen JR, Garwood D, Glatstein E, Neuwelt EA: Neurobehavioral sequelae of cranial irradiation in adults: a review of radiation-induced encephalopathy. J Clin Oncol 12:627642, 1994

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    DeAngelis LM, Delattre JY, Posner JB: Radiation-induced dementia in patients cured of brain metastases. Neurology 39:789796, 1989

  • 15

    Eaton BR, LaRiviere MJ, Kim S, Prabhu RS, Patel K, Kandula S, : Hypofractionated radiosurgery has a better safety profile than single fraction radiosurgery for large resected brain metastases. J Neurooncol 123:103111, 2015 (Erratum in J Neurooncol 123:113, 2015)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16

    Ebner D, Rava P, Gorovets D, Cielo D, Hepel JT: Stereotactic radiosurgery for large brain metastases. J Clin Neurosci 22:16501654, 2015

  • 17

    Eisenhauer EA, Therasse P, Bogaerts J, Schwartz LH, Sargent D, Ford R, : New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer 45:228247, 2009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Feuvret L, Vinchon S, Martin V, Lamproglou I, Halley A, Calugaru V, : Stereotactic radiotherapy for large solitary brain metastases. Cancer Radiother 18:97106, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Fokas E, Henzel M, Surber G, Kleinert G, Hamm K, Engenhart-Cabillic R: Stereotactic radiosurgery and fractionated stereotactic radiotherapy: comparison of efficacy and toxicity in 260 patients with brain metastases. J Neurooncol 109:9198, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Gaspar L, Scott C, Rotman M, Asbell S, Phillips T, Wasserman T, : Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy Oncology Group (RTOG) brain metastases trials. Int J Radiat Oncol Biol Phys 37:745751, 1997

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Hall EJ, Giaccia AJ: Radiobiology for the Radiologist. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2012

    • Export Citation
  • 22

    Han JH, Kim DG, Chung HT, Paek SH, Park CK, Jung HW: Radiosurgery for large brain metastases. Int J Radiat Oncol Biol Phys 83:113120, 2012

  • 23

    Han JH, Kim DG, Kim CY, Chung HT, Jung HW: Stereotactic radiosurgery for large brain metastases. Prog Neurol Surg 25:248260, 2012

  • 24

    Higuchi Y, Serizawa T, Nagano O, Matsuda S, Ono J, Sato M, : Three-staged stereotactic radiotherapy without whole brain irradiation for large metastatic brain tumors. Int J Radiat Oncol Biol Phys 74:15431548, 2009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Inoue HK, Sato H, Suzuki Y, Saitoh J, Noda SE, Seto K, : Optimal hypofractionated conformal radiotherapy for large brain metastases in patients with high risk factors: a single-institutional prospective study. Radiat Oncol 9:231, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Jagannathan J, Yen CP, Ray DK, Schlesinger D, Oskouian RJ, Pouratian N, : Gamma Knife radiosurgery to the surgical cavity following resection of brain metastases. J Neurosurg 111:431438, 2009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Jeong WJ, Park JH, Lee EJ, Kim JH, Kim CJ, Cho YH: Efficacy and safety of fractionated stereotactic radiosurgery for large brain metastases. J Korean Neurosurg Soc 58:217224, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Jiang XS, Xiao JP, Zhang Y, Xu YJ, Li XP, Chen XJ, : Hypofractionated stereotactic radiotherapy for brain metastases larger than three centimeters. Radiat Oncol 7:36, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Kalkanis SN, Kondziolka D, Gaspar LE, Burri SH, Asher AL, Cobbs CS, : The role of surgical resection in the management of newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline. J Neurooncol 96:3343, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Kocher M, Soffietti R, Abacioglu U, Villà S, Fauchon F, Baumert BG, : Adjuvant whole-brain radiotherapy versus observation after radiosurgery or surgical resection of one to three cerebral metastases: results of the EORTC 22952-26001 study. J Clin Oncol 29:134141, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Kondziolka D, Niranjan A, Flickinger JC, Lunsford LD: Radiosurgery with or without whole-brain radiotherapy for brain metastases: the patients’ perspective regarding complications. Am J Clin Oncol 28:173179, 2005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Lee CC, Yen CP, Xu Z, Schlesinger D, Sheehan J: Large intracranial metastatic tumors treated by Gamma Knife surgery: outcomes and prognostic factors. J Neurosurg 120:5259, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Lin X, DeAngelis LM: Treatment of Brain Metastases. J Clin Oncol 33:34753484, 2015

  • 34

    Luther N, Kondziolka D, Kano H, Mousavi SH, Engh JA, Niranjan A, : Predicting tumor control after resection bed radiosurgery of brain metastases. Neurosurgery 73:10011006, 2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Mehta MP, Tsao MN, Whelan TJ, Morris DE, Hayman JA, Flickinger JC, : The American Society for Therapeutic Radiology and Oncology (ASTRO) evidence-based review of the role of radiosurgery for brain metastases. Int J Radiat Oncol Biol Phys 63:3746, 2005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Metellus P, Bialecki E, Le Rhun E, Dhermain F: Neurosurgical and radiosurgical decision making in brain metastasis patients in the area of targeted therapies? Chin Clin Oncol 4:19, 2015

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Minniti G, Clarke E, Lanzetta G, Osti MF, Trasimeni G, Bozzao A, : Stereotactic radiosurgery for brain metastases: analysis of outcome and risk of brain radionecrosis. Radiat Oncol 6:48, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Minniti G, D’Angelillo RM, Scaringi C, Trodella LE, Clarke E, Matteucci P, : Fractionated stereotactic radiosurgery for patients with brain metastases. J Neurooncol 117:295301, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Minniti G, Scaringi C, Paolini S, Lanzetta G, Romano A, Cicone F, : Single-fraction versus multifraction (3 × 9 Gy) stereotactic radiosurgery for large (>2 cm) brain metastases: a comparative analysis of local control and risk of radiation-induced brain necrosis. Int J Radiat Oncol Biol Phys 95:11421148, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Mohammadi AM, Schroeder JL, Angelov L, Chao ST, Murphy ES, Yu JS, : Impact of the radiosurgery prescription dose on the local control of small (2 cm or smaller) brain metastases. J Neurosurg 126:735743, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41

    Molenaar R, Wiggenraad R, Verbeek-de Kanter A, Walchenbach R, Vecht C: Relationship between volume, dose and local control in stereotactic radiosurgery of brain metastasis. Br J Neurosurg 23:170178, 2009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42

    Murai T, Ogino H, Manabe Y, Iwabuchi M, Okumura T, Matsushita Y, : Fractionated stereotactic radiotherapy using CyberKnife for the treatment of large brain metastases: a dose escalation study. Clin Oncol (R Coll Radiol) 26:151158, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43

    Narayana A, Chang J, Yenice K, Chan K, Lymberis S, Brennan C, : Hypofractionated stereotactic radiotherapy using intensity-modulated radiotherapy in patients with one or two brain metastases. Stereotact Funct Neurosurg 85:8287, 2007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44

    Navarria P, Pessina F, Cozzi L, Ascolese AM, De Rose F, Fogliata A, : Hypo-fractionated stereotactic radiotherapy alone using volumetric modulated arc therapy for patients with single, large brain metastases unsuitable for surgical resection. Radiat Oncol 11:76, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45

    Nieder C, Berberich W, Schnabel K: Tumor-related prognostic factors for remission of brain metastases after radiotherapy. Int J Radiat Oncol Biol Phys 39:2530, 1997

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46

    Ogura K, Mizowaki T, Ogura M, Sakanaka K, Arakawa Y, Miyamoto S, : Outcomes of hypofractionated stereotactic radiotherapy for metastatic brain tumors with high risk factors. J Neurooncol 109:425432, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 47

    Park C, Papiez L, Zhang S, Story M, Timmerman RD: Universal survival curve and single fraction equivalent dose: useful tools in understanding potency of ablative radiotherapy. Int J Radiat Oncol Biol Phys 70:847852, 2008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 48

    Patchell RA, Tibbs PA, Regine WF, Dempsey RJ, Mohiuddin M, Kryscio RJ, : Postoperative radiotherapy in the treatment of single metastases to the brain: a randomized trial. JAMA 280:14851489, 1998

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 49

    Patchell RA, Tibbs PA, Walsh JW, Dempsey RJ, Maruyama Y, Kryscio RJ, : A randomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med 322:494500, 1990

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 50

    Patel TR, McHugh BJ, Bi WL, Minja FJ, Knisely JP, Chiang VL: A comprehensive review of MR imaging changes following radiosurgery to 500 brain metastases. AJNR Am J Neuroradiol 32:18851892, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 51

    Pessina F, Navarria P, Cozzi L, Ascolese AM, Maggi G, Riva M, : Outcome evaluation of oligometastatic patients treated with surgical resection followed by hypofractionated stereotactic radiosurgery (HSRS) on the tumor bed, for single, large brain metastases. PLoS One 11:e0157869, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 52

    Pessina F, Navarria P, Cozzi L, Ascolese AM, Maggi G, Rossi M, : The role of surgical resection in patients with single large brain metastases: feasibility, morbidity and local control evaluation. World Neurosurg 94:612, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 53

    Qian JM, Yu JB, Kluger HM, Chiang VL: Timing and type of immune checkpoint therapy affect the early radiographic response of melanoma brain metastases to stereotactic radiosurgery. Cancer 122:30513058, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 54

    Sanghavi SN, Miranpuri SS, Chappell R, Buatti JM, Sneed PK, Suh JH, : Radiosurgery for patients with brain metastases: a multi-institutional analysis, stratified by the RTOG recursive partitioning analysis method. Int J Radiat Oncol Biol Phys 51:426434, 2001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 55

    Serizawa T, Saeki N, Higuchi Y, Ono J, Iuchi T, Nagano O, : Gamma knife surgery for brain metastases: indications for and limitations of a local treatment protocol. Acta Neurochir (Wien) 147:721726, 2005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 56

    Shaw E, Scott C, Souhami L, Dinapoli R, Kline R, Loeffler J, : Single dose radiosurgical treatment of recurrent previously irradiated primary brain tumors and brain metastases: final report of RTOG protocol 90-05. Int J Radiat Oncol Biol Phys 47:291298, 2000

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 57

    Sheehan JP, Sun MH, Kondziolka D, Flickinger J, Lunsford LD: Radiosurgery for non-small cell lung carcinoma metastatic to the brain: long-term outcomes and prognostic factors influencing patient survival time and local tumor control. J Neurosurg 97:12761281, 2002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 58

    Sheline GE, Wara WM, Smith V: Therapeutic irradiation and brain injury. Int J Radiat Oncol Biol Phys 6:12151228, 1980

  • 59

    Shuryak I, Carlson DJ, Brown JM, Brenner DJ: High-dose and fractionation effects in stereotactic radiation therapy: Analysis of tumor control data from 2965 patients. Radiother Oncol 115:327334, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 60

    Sneed PK, Mendez J, Vemer-van den Hoek JG, Seymour ZA, Ma L, Molinaro AM, : Adverse radiation effect after stereotactic radiosurgery for brain metastases: incidence, time course, and risk factors. J Neurosurg 123:373386, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 61

    Sneed PK, Suh JH, Goetsch SJ, Sanghavi SN, Chappell R, Buatti JM, : A multi-institutional review of radiosurgery alone vs. radiosurgery with whole brain radiotherapy as the initial management of brain metastases. Int J Radiat Oncol Biol Phys 53:519526, 2002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 62

    Soliman H, Das S, Larson DA, Sahgal A: Stereotactic radiosurgery (SRS) in the modern management of patients with brain metastases. Oncotarget 7:1231812330, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 63

    Sperduto PW, Berkey B, Gaspar LE, Mehta M, Curran W: A new prognostic index and comparison to three other indices for patients with brain metastases: an analysis of 1,960 patients in the RTOG database. Int J Radiat Oncol Biol Phys 70:510514, 2008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 64

    Sperduto PW, Kased N, Roberge D, Xu Z, Shanley R, Luo X, : Summary report on the graded prognostic assessment: an accurate and facile diagnosis-specific tool to estimate survival for patients with brain metastases. J Clin Oncol 30:419425, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 65

    Suh JH: Stereotactic radiosurgery for the management of brain metastases. N Engl J Med 362:11191127, 2010

  • 66

    Tallet AV, Azria D, Barlesi F, Spano JP, Carpentier AF, Gonçalves A, : Neurocognitive function impairment after whole brain radiotherapy for brain metastases: actual assessment. Radiat Oncol 7:77, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 67

    Tsao MN, Lloyd N, Wong RK, Chow E, Rakovitch E, Laperriere N, : Whole brain radiotherapy for the treatment of newly diagnosed multiple brain metastases. Cochrane Database Syst Rev (4):CD003869, 2012

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 68

    Varlotto JM, Flickinger JC, Niranjan A, Bhatnagar AK, Kondziolka D, Lunsford LD: Analysis of tumor control and toxicity in patients who have survived at least one year after radiosurgery for brain metastases. Int J Radiat Oncol Biol Phys 57:452464, 2003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 69

    Vecht CJ, Haaxma-Reiche H, Noordijk EM, Padberg GW, Voormolen JH, Hoekstra FH, : Treatment of single brain metastasis: radiotherapy alone or combined with neurosurgery? Ann Neurol 33:583590, 1993

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 70

    Vogelbaum MA, Angelov L, Lee SY, Li L, Barnett GH, Suh JH: Local control of brain metastases by stereotactic radiosurgery in relation to dose to the tumor margin. J Neurosurg 104:907912, 2006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 71

    Wegner RE, Leeman JE, Kabolizadeh P, Rwigema JC, Mintz AH, Burton SA, : Fractionated stereotactic radiosurgery for large brain metastases. Am J Clin Oncol 38:135139, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 72

    Wiggenraad R, Verbeek-de Kanter A, Mast M, Molenaar R, Kal HB, Lycklama à Nijeholt G, : Local progression and pseudo progression after single fraction or fractionated stereotactic radiotherapy for large brain metastases. A single centre study. Strahlenther Onkol 188:696701, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 73

    Yang HC, Kano H, Lunsford LD, Niranjan A, Flickinger JC, Kondziolka D: What factors predict the response of larger brain metastases to radiosurgery? Neurosurgery 68:682690, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 74

    Yomo S, Hayashi M: A minimally invasive treatment option for large metastatic brain tumors: long-term results of two-session Gamma Knife stereotactic radiosurgery. Radiat Oncol 9:132, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 75

    Yomo S, Hayashi M, Nicholson C: A prospective pilot study of two-session Gamma Knife surgery for large metastatic brain tumors. J Neurooncol 109:159165, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 76

    Zimmerman AL, Murphy ES, Suh JH, Vogelbaum MA, Barnett GH, Angelov L, : Treatment of large brain metastases with stereotactic radiosurgery. Technol Cancer Res Treat 15:186195, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 178 0 0
Full Text Views 1300 617 56
PDF Downloads 761 317 26
EPUB Downloads 0 0 0