TY - JOUR
T1 - Neoadjuvant stereotactic radiosurgery for brain metastases
T2 - a new paradigm
AU - Li, Yuping Derek
AU - Coxon, Andrew T.
AU - Huang, Jiayi
AU - Abraham, Christopher
AU - Dowling, Joshua
AU - Leuthardt, Eric C.
AU - Dunn, Gavin
AU - Kim, Albert
AU - Dacey, Ralph G.
AU - Zipfel, Gregory J.
AU - Evans, John
AU - Filiput, Eric A.
AU - Chicoine, Michael
N1 - Funding Information:
I-MiND is maintained in The REDCap server at Washington University in St. Louis and is supported by Clinical and Translational Science Award (CTSA) Grant (UL1 TR000448) and The Siteman Comprehensive Cancer Center and NCI Cancer Center Support Grant (P30 CA091842).
Funding Information:
Dr. Chicoine: funding from IMRIS Inc. for an unrestricted educational grant to support an intraoperative MRI and brain tumor database and outcomes analysis project (the IMRIS Multicenter intraoperative MRI Neurosurgery Database [I-MiND]), The Head for the Cure Foundation, Mrs. Carol Rossfeld and The Alex & Alice Aboussie Family Charitable Foundation, and Mr. and Mrs. Barbara and George Holtzman. Dr. Dunn: cofounder of Immunovalent. Dr. Kim: consultant for Monteris Medical and non–study-related clinical or research effort from Monteris Medical, Stryker, and Collagen Matrix. Dr. Zipfel: grant funding via the NIH National Institute of Neurological Disorders and Stroke (NINDS). Dr. Leuthardt: ownership in Neurolutions, Sora Neuroscience, Inner Cosmos, and Inner Cosmos; and consultant for E15.
Publisher Copyright:
© AANS 2022, except where prohibited by US copyright law
PY - 2022
Y1 - 2022
N2 - OBJECTIVE For patients with surgically accessible solitary metastases or oligometastatic disease, treatment often involves resection followed by postoperative stereotactic radiosurgery (SRS). This strategy has several potential drawbacks, including irregular target delineation for SRS and potential tumor “seeding” away from the resection cavity during surgery. A neoadjuvant (preoperative) approach to radiation therapy avoids these limitations and offers improved patient convenience. This study assessed the efficacy of neoadjuvant SRS as a new treatment paradigm for patients with brain metastases. METHODS A retrospective review was performed at a single institution to identify patients who had undergone neoadjuvant SRS (specifically, Gamma Knife radiosurgery) followed by resection of a brain metastasis. Kaplan-Meier survival and log-rank analyses were used to evaluate risks of progression and death. Assessments were made of local recurrence and leptomeningeal spread. Additionally, an analysis of the contemporary literature of postoperative and neoadjuvant SRS for metastatic disease was performed. RESULTS Twenty-four patients who had undergone neoadjuvant SRS followed by resection of a brain metastasis were identified in the single-institution cohort. The median age was 64 years (range 32–84 years), and the median follow-up time was 16.5 months (range 1 month to 5.7 years). The median radiation dose was 17 Gy prescribed to the 50% isodose. Rates of local disease control were 100% at 6 months, 87.6% at 12 months, and 73.5% at 24 months. In 4 patients who had local treatment failure, salvage therapy included repeat resection, laser interstitial thermal therapy, or repeat SRS. One hundred thirty patients (including the current cohort) were identified in the literature who had been treated with neoadjuvant SRS prior to resection. Overall rates of local control at 1 year after neoadjuvant SRS treatment ranged from 49% to 91%, and rates of leptomeningeal dissemination from 0% to 16%. In comparison, rates of local control 1 year after postoperative SRS ranged from 27% to 91%, with 7% to 28% developing leptomeningeal disease. CONCLUSIONS Neoadjuvant SRS for the treatment of brain metastases is a novel approach that mitigates the shortcomings of postoperative SRS. While additional prospective studies are needed, the current study of 130 patients including the summary of 106 previously published cases supports the safety and potential efficacy of preoperative SRS with potential for improved outcomes compared with postoperative SRS.
AB - OBJECTIVE For patients with surgically accessible solitary metastases or oligometastatic disease, treatment often involves resection followed by postoperative stereotactic radiosurgery (SRS). This strategy has several potential drawbacks, including irregular target delineation for SRS and potential tumor “seeding” away from the resection cavity during surgery. A neoadjuvant (preoperative) approach to radiation therapy avoids these limitations and offers improved patient convenience. This study assessed the efficacy of neoadjuvant SRS as a new treatment paradigm for patients with brain metastases. METHODS A retrospective review was performed at a single institution to identify patients who had undergone neoadjuvant SRS (specifically, Gamma Knife radiosurgery) followed by resection of a brain metastasis. Kaplan-Meier survival and log-rank analyses were used to evaluate risks of progression and death. Assessments were made of local recurrence and leptomeningeal spread. Additionally, an analysis of the contemporary literature of postoperative and neoadjuvant SRS for metastatic disease was performed. RESULTS Twenty-four patients who had undergone neoadjuvant SRS followed by resection of a brain metastasis were identified in the single-institution cohort. The median age was 64 years (range 32–84 years), and the median follow-up time was 16.5 months (range 1 month to 5.7 years). The median radiation dose was 17 Gy prescribed to the 50% isodose. Rates of local disease control were 100% at 6 months, 87.6% at 12 months, and 73.5% at 24 months. In 4 patients who had local treatment failure, salvage therapy included repeat resection, laser interstitial thermal therapy, or repeat SRS. One hundred thirty patients (including the current cohort) were identified in the literature who had been treated with neoadjuvant SRS prior to resection. Overall rates of local control at 1 year after neoadjuvant SRS treatment ranged from 49% to 91%, and rates of leptomeningeal dissemination from 0% to 16%. In comparison, rates of local control 1 year after postoperative SRS ranged from 27% to 91%, with 7% to 28% developing leptomeningeal disease. CONCLUSIONS Neoadjuvant SRS for the treatment of brain metastases is a novel approach that mitigates the shortcomings of postoperative SRS. While additional prospective studies are needed, the current study of 130 patients including the summary of 106 previously published cases supports the safety and potential efficacy of preoperative SRS with potential for improved outcomes compared with postoperative SRS.
KW - Brain metastasis
KW - Neoadjuvant stereotactic radiosurgery
KW - Preoperative
KW - Resection
UR - http://www.scopus.com/inward/record.url?scp=85141144804&partnerID=8YFLogxK
U2 - 10.3171/2022.8.FOCUS22367
DO - 10.3171/2022.8.FOCUS22367
M3 - Article
C2 - 36321291
AN - SCOPUS:85141144804
SN - 1092-0684
VL - 53
JO - Neurosurgical focus
JF - Neurosurgical focus
IS - 5
M1 - E8
ER -