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Hypofractionated stereotactic radiosurgery (HSRS) as a salvage treatment for brain metastases failing prior stereotactic radiosurgery (SRS)

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Various treatment options exist to salvage stereotactic radiosurgery (SRS) failures for brain metastases, including repeat SRS and hypofractionated SRS (HSRS). Our objective was to report outcomes specific to salvage HSRS for brain metastases that failed prior HSRS/SRS.


Patients treated with HSRS to salvage local failures (LF) following initial HSRS/SRS, between July 2010 and April 2020, were retrospectively reviewed. The primary outcomes were the rates of LF, radiation necrosis (RN), and symptomatic radiation necrosis (SRN). Univariable (UVA) and multivariable (MVA) analyses using competing risk regression were performed to identify predictive factors for each endpoint.


120 Metastases in 91 patients were identified. The median clinical follow up was 13.4 months (range 1.1–111.1), and the median interval between SRS courses was 13.1 months (range 3.0–56.5). 115 metastases were salvaged with 20–35 Gy in 5 fractions and the remaining five with a total dose ranging from 20 to 24 Gy in 3-fractions. 67 targets (56%) were postoperative cavities. The median re-treatment target volume and biological effective dose (BED10) was 9.5 cc and 37.5 Gy, respectively. The 6- and 12- month LF rates were 18.9% and 27.7%, for RN 13% and 15.6%, and for SRN were 6.1% and 7.0%, respectively. MVA identified larger re-irradiation volume (hazard ratio [HR] 1.02, p = 0.04) and shorter interval between radiosurgery courses (HR 0.93, p < 0.001) as predictors of LF. Treatment of an intact target was associated with a higher risk of RN (HR 2.29, p = 0.04).


Salvage HSRS results in high local control rates and toxicity rates that compare favorably to those single fraction SRS re-irradiation experiences reported in the literature.

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Authors and Affiliations



MY, AS, and HS developed study concept. MY, ML, and HS obtained study data. MY was responsible for statistical analysis. MY and HS wrote the initial manuscript draft. MY and LH prepared all figures and tables. All authors reviewed manuscript and final approval.

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Correspondence to Hany Soliman.

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Conflict of interest

HS reports travel and education grants from Elekta. SD reports research grants from Alkermes Medical and consultant fees from Medexus. SM reports research support and honoraria from AAA/Novartis and Ipsen. CLT reports honoraria from Elekta and serves on the advisory board for Sanofi. AS reports consulting fees and grants from Varian and Elekta, as well as honoraria from Varian, BrainLab, and Elekta. MR owns intellectual property related to the image-guidance component on the Elekta Gamma Knife system. All other authors have no disclosures.

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Yan, M., Lee, M., Myrehaug, S. et al. Hypofractionated stereotactic radiosurgery (HSRS) as a salvage treatment for brain metastases failing prior stereotactic radiosurgery (SRS). J Neurooncol 162, 119–128 (2023).

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