Outcomes and prognostic stratification of patients with recurrent glioblastoma treated with salvage stereotactic radiosurgery

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Glioblastoma (GBM) is the most malignant form of astrocytoma. The average survival is 6–10 months in patients with recurrent GBM (rGBM). In this study, the authors evaluated the role of stereotactic radiosurgery (SRS) in patients with rGBMs.


The authors performed a retrospective review of their brain tumor database (1997–2016). Overall survival (OS) and progression-free survival (PFS) after salvage SRS were the primary endpoints evaluated. Response to SRS was assessed using volumetric MR images.


Fifty-three patients with rGBM underwent salvage SRS targeting 75 lesions. The median tumor diameter and volume were 2.55 cm and 3.80 cm3, respectively. The median prescription dose was 18 Gy (range 12–24 Gy) and the homogeneity index was 1.90 (range 1.11–2.02). The median OS after salvage SRS was estimated to be 11.0 months (95% CI 7.1–12.2) and the median PFS after salvage SRS was 4.4 months (95% CI 3.7–5.0). A Karnofsky Performance Scale score ≥ 80 was independently associated with longer OS, while small tumor volume (< 15 cm3) and less homogeneous treatment plans (homogeneity index > 1.75) were both independently associated with longer OS (p = 0.007 and 0.03) and PFS (p = 0.01 and 0.002, respectively). Based on these factors, 2 prognostic groups were identified for PFS (5.4 vs 3.2 months), while 3 were identified for OS (median OS of 15.2 vs 10.5 vs 5.2 months).


SRS is associated with longer OS and/or PFS in patients with good performance status, small-volume tumor recurrences, and heterogeneous treatment plans. The authors propose a prognostic model to identify a cohort of rGBM patients who may benefit from SRS.

ABBREVIATIONS EBRT = external-beam radiotherapy; GBM = glioblastoma; GKRS = Gamma Knife radiosurgery; KPS = Karnofsky Performance Scale; LITT = laser interstitial thermal therapy; MGMT = O6-methylguanine-DNA methyltransferase; OS = overall survival; PFS = progression-free survival; rGBM = recurrent GBM; RPA = recursive partitioning analysis; SRS = stereotactic radiosurgery; WBRT = whole-brain radiation therapy.

Article Information

Correspondence Lilyana Angelov: Cleveland Clinic, Cleveland, OH. angelol@ccf.org.

INCLUDE WHEN CITING Published online October 19, 2018; DOI: 10.3171/2018.4.JNS172909.

Disclosures Dr. Barnett is a consultant for Elekta. Dr. Mohammadi is a consultant for Monteris Medical.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Kaplan-Meier curves showing the percentage of PFS and OS in patients following SRS for rGBM.

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    Kaplan-Meier curves showing PFS (left) in patients stratified into prognostic groups (favorable: homogeneity index > 1.75 and total volume < 15 cm3; unfavorable: index ≤ 1.75 and/or total volume ≥ 15 cm3) and OS (right) in patients stratified into prognostic groups (favorable: 0 poor prognostic features; intermediate: 1 poor prognostic feature; unfavorable: 2 or 3 poor prognostic features) following salvage SRS for rGBM. The poor prognostic features were KPS score < 80, total tumor volume ≥ 15 cm3, and homogeneity index ≤ 1.75.

  • View in gallery

    Illustrative case of a 61-year-old man who presented with rGBM following standard concurrent chemoradiotherapy and 3 cycles of adjunct chemotherapy. He exhibited a good response to salvage SRS (22 Gy at 50% isodose line; homogeneity index 2.005) at the 9.4-month follow-up (pretreatment axial [A] and sagittal [B] postgadolinium T1-weighted MR images and postgadolinium axial [C] and sagittal [D] T1-weighted MR images at last follow-up). Figure is available in color online only.


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