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William T. Curry Jr., Garth Rees Cosgrove, Fred H. Hochberg, Jay Loeffler, and Nicholas T. Zervas

R oughly 25% of patients with systemic cancer suffer from brain metastases, accounting for more than 100,000 new cases per year in the US. The results of two randomized trials have demonstrated that survival for patients with a single brain metastasis is markedly lengthened by adding resection to the standard treatment of WBRT. 13, 17 For lesions that are 3 cm in diameter or smaller, stereotactic radiosurgery performed using a gamma knife or a linear accelerator achieves local control that is comparable to resection and, likewise, permits long-term survival

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Current and novel practice of stereotactic radiosurgery

JNSPG 75th Anniversary Invited Review Article

Douglas Kondziolka

fortunately have been relatively infrequent. Published dose-response data have led to improvements in safe outcomes. This report describes elements of current practice, expanding concepts, and new avenues for investigation. Technical Aspects of Stereotactic Radiosurgery A number of different technologies are available to perform radiosurgery procedures. These continue to include photon- and proton-based devices. Established devices used to care for large numbers of patients include the Leksell Gamma Knife (Elekta AB), the CyberKnife (Accuray Inc.), and different modified

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Douglas Kondziolka, L. Dade Lunsford, Robert J. Coffey, and John C. Flickinger

perform incomplete resections. Some patients with meningiomas are considered unsuitable for surgery if they are elderly or are “medically unfit.” 2, 13 Single-fraction precisely guided multiple photon-beam irradiation (stereotactic radiosurgery) offers treatment to such patients: those with tumors in high-risk locations; those with residual meningiomas after surgical resection; and those whose advanced age or associated medical illness pose unacceptable risks for surgical removal. This report is the first comprehensive clinical analysis of stereotactic radiosurgery

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Elizabeth Tyler-Kabara, Douglas Kondziolka, John C. Flickinger, and L. Dade Lunsford

tumors in critical locations that remain after resection or biopsy procedures, subsequent management options have included observation, radiation therapy, and now stereotactic radiosurgery. We report results in four patients who underwent radiosurgery for persistent neurocytomas. Case Reports Case 1 This 16-year-old young woman underwent two resections (one transfrontal and one transcallosal) for a large lateral and third ventricular tumor. The majority of the neurocytoma was removed during the first two surgeries. Residual tumor was seen in the left lateral

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Bruce E. Pollock, Yolanda I. Garces, Scott L. Stafford, Robert L. Foote, Paula J. Schomberg, and Michael J. Link

symptomatic lesions. 3, 18, 21 Removal of the lesion provides relief of mass effect, reduction in seizure frequency, and immediate protection against future intracranial hemorrhage. The use of stereotactic radiosurgery for treating CMs is controversial. Kondziolka and colleagues 14 reported 47 cases of CMs managed with radiosurgery between 1987 and 1994. At a mean follow-up period of 3.6 years, these authors reported a significant reduction in bleeding risk that was most notable 2 or more years after the procedure. Twelve patients (26%) suffered a neurological decline

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Chuan-Fu Huang, Douglas Kondziolka, John C. Flickinger, and L. Dade Lunsford

neurological defects and the poor overall expected survival rates. Stereotactic radiosurgery is a potentially useful therapeutic strategy that provides high-dose irradiation to a localized tumor volume in a single session. It is not limited by tumor location or depth but rather the ability to image a well-defined target within stereotactic space. Although brainstem metastases may be unsuitable for microsurgical resection because of their location, this limitation does not preclude radiosurgery. Because radiosurgery is an alternative to surgical resection for many brain

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Douglas Kondziolka, Ricky Madhok, L. Dade Lunsford, David Mathieu, Juan J. Martin, Ajay Niranjan, and John C. Flickinger

treatment for symptomatic patients with these tumor types. 20 Image guidance techniques have allowed the optimal creation of craniotomies that extend beyond the tumor margin to facilitate removal of any involved dura mater or bone. Nevertheless, resection is not always feasible if the tumor presents in an elderly or frail patient, or when it is located adjacent to critical brain regions or important cortical veins. Stereotactic radiosurgery is an effective strategy for basal meningiomas. 9 , 13 , 15 , 16 The role of radiosurgery for convexity meningiomas has been

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Gerhard M. Friehs, Michael C. Park, Marc A. Goldman, Vasilios A. Zerris, Georg Norén, and Prakash Sampath

have achieved long-term and significant reduction of OCD symptoms in roughly two thirds of our patients. Preliminary findings are encouraging but longer follow-up is needed. Conclusions There is sufficient evidence in the literature to support the use of radiosurgery in the treatment of certain functional disorders. Stereotactic radiosurgery has become a standard neurosurgical tool for the treatment of TN because of favorable results and very limited risk of complications. Radiosurgical treatment of some other pain syndromes is promising with certain techniques

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Nelson M. Oyesiku

–80%. 4 , 8 , 22 , 31 , 37 , 38 , 41 Currently, SRS or fractionated stereotactic radiotherapy is the main of adjuvant treatment for CD after failed surgery. 20 , 33 , 39 Conventional radiotherapy, although successful, is now used less often because of the availability and efficacy of the stereotactic therapies. 13 , 21 Stereotactic radiosurgery was introduced in Sweden in 1969 by Lars Leksell and has since been used successfully in the treatment of ACTH-producing adenomas. The current indications for SRS include the following: 1) a previously failed resection; 2) a

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Salvador Somaza, Douglas Kondziolka, L. Dade Lunsford, John M. Kirkwood, and John C. Flickinger

Chemotherapeutic agents, various protocols for fractionated radiation therapy, 19, 20, 33 and immunotherapy have been used alone or sometimes after surgical resection. Despite these efforts, the prognosis for a patient with single or multiple melanoma metastasis to the brain remains poor (median survival 2 to 3 months). 28 Stereotactic radiosurgery is an attractive therapeutic strategy less invasive than other modalities that provides high-dose, single-session irradiation to a localized tumor volume. Recent reports indicate that radiosurgery is being used in an increasing