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Utilization of neoadjuvant stereotactic radiosurgery for the treatment of brain metastases requiring surgical resection: a topic review

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Abstract

Purpose

Following surgical resection of brain metastases (BMs), adjuvant stereotactic radiosurgery (SRS) has become the standard of care post-operative cavity irradiation. Recent studies, however, have demonstrated that with the current sequence of surgery and radiation, risk of leptomeningeal disease (LMD) and radiation necrosis (RN) remains high. Pre-operative, or neoadjuvant, SRS (nSRS) has been proposed as an alternative treatment strategy which not only minimizes local recurrence (LR) but also LMD and RN. It is thought that nSRS sterilizes the tumor, allowing for minimal spillage of viable tumor cells during resection, creating less favorable conditions for LMD. Furthermore, nSRS allows for easier contouring and decreased margin irradiation during planning and treatment, respectively, diminishing the risk of symptomatic RN. While nSRS has already been adopted for treating other extra-cranial tumors, its role in treating BMs is yet to be defined. We aim to summarize recent studies in nSRS usage for BMs and the rationale of this treatment strategy.

Methods

We performed a search for articles regarding nSRS for BMs published in PubMed from 2018 to 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method. We summarized a total of 14 retrospective reviews, case series, dose/timing studies, and ongoing Phase II & III clinical trials.

Conclusion

In this review, we describe the findings of current studies and identify prospective clinical trials with the aim of understanding the efficacy of nSRS over current treatment standards. Herein, we also discuss the theoretical advantages and limitations of nSRS (both biologic and clinical) to help guide future clinical investigations.

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Acknowledgements

The authors thank Sarah Carey, MS, Jade Chang, and Jacalyn Newman, PhD, of Allegheny Health Network’s Health System Publication Support Office (HSPSO) for their assistance in editing and formatting the manuscript. The HSPSO is funded by Highmark Health (Pittsburgh, PA, United States of America) and all work was done in accordance with Good Publication Practice (GPP3) guidelines (http://www.ismpp.org/gpp3).

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The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

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Authors and Affiliations

  1. Drexel University College of Medicine, Philadelphia, PA, USA

    Sujay Rajkumar

  2. Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA

    Yun Liang & Rodney E. Wegner

  3. Department of Neurosurgery, Allegheny Health Network Neuroscience Institute, Pittsburgh, PA, USA

    Matthew J. Shepard

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All authors contributed to the content of the review. Material preparation and literature review was performed by all authors. The first draft of the manuscript was written by SR, and all authors commented on subsequent versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Matthew J. Shepard.

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Rodney Wegner, MD has received grant funding from Elekta (not in support of this study). No other authors have declared financial interests.

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Rajkumar, S., Liang, Y., Wegner, R.E. et al. Utilization of neoadjuvant stereotactic radiosurgery for the treatment of brain metastases requiring surgical resection: a topic review. J Neurooncol 160, 691–705 (2022). https://doi.org/10.1007/s11060-022-04190-6

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