Skip to main content

Stereotactic Radiosurgery: Indications and Outcomes in Central Nervous System and Skull Base Metastases

  • Chapter
  • First Online:
Central Nervous System Metastases

Abstract

The most recent advances in the management of systemic cancer disease have likely led to an increase in the number of patients with brain metastases. In this setting, stereotactic radiosurgery (SRS) has risen as a mainstay treatment in the management of patients diagnosed with metastatic brain lesions. Given its favorable toxicity profile over conventional radiotherapy, a continuously growing body of prospective randomized data has allowed SRS to extend the reach of local therapy both as adjuvant and/or definitive treatment of brain metastases.

Conventional indications such as postoperative resection cavity SRS as well as novel approaches such as hypofractionation and preoperative SRS will be discussed in this chapter in an attempt to optimize patient selection and improve both oncologic control and quality of life.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 129.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 169.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 249.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Similar content being viewed by others

Abbreviations

ASTRO:

American Society for Radiation Oncology

CDFS:

Cognitive Deterioration Free Survival

CP:

Cognitive preservation

CSF:

Cerebrospinal fluid

CT:

Computed tomography

CTV:

Clinical target volume

DS-GPA:

Diagnosis-specific Graded Prognostic Assessment

EORTC:

European Organization for Research and Treatment of Cancer

FI:

Functional independence

GPA:

Graded Prognostic Assessment

GTV:

Gross tumor volume

HSRS:

Hypofractionated stereotactic radiosurgery

KPS:

Karnofsky Performance Status

LC:

Local control

LINAC:

Linear accelerator

LMD:

Leptomeningeal disease

MRI:

Magnetic resonance imaging

NCCN:

National Comprehensive Cancer Network

NSCLC:

Non-small cell lung cancer

OS:

Overall survival

PTV:

Planning target volume

QoL:

Quality of life

RCT:

Randomized controlled clinical trial

RN:

Radiation necrosis

RPA:

Recursive partitioning analysis

RTOG:

Radiation Therapy Oncology Group

SRS:

Stereotactic radiosurgery

UPMC:

University of Pittsburgh Medical Center

WBRT:

Whole-brain radiotherapy

References

  1. Dagogo-Jack I, Carter SL, Brastianos PK. Brain metastasis: clinical implications of branched evolution. Trends Cancer. 2016;2(7):332–7.

    Article  PubMed  Google Scholar 

  2. Brown PD, Jaeckle K, Ballman KV, Farace E, Cerhan JH, Anderson SK, et al. Effect of radiosurgery alone vs radiosurgery with whole brain radiation therapy on cognitive function in patients with 1 to 3 brain metastases: a randomized clinical trial. JAMA. 2016;316(4):401–9.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Yamamoto M, Serizawa T, Shuto T, Akabane A, Higuchi Y, Kawagishi J, et al. Stereotactic radiosurgery for patients with multiple brain metastases (JLGK0901): a multi-institutional prospective observational study. Lancet Oncol. 2014;15(4):387–95.

    Article  PubMed  Google Scholar 

  4. Flickinger JC, Lunsford LD, Somaza S, Kondziolka D. Radiosurgery: its role in brain metastasis management. Neurosurg Clin N Am. 1996;7(3):497–504.

    Article  CAS  PubMed  Google Scholar 

  5. Gerosa M, Nicolato A, Foroni R, Zanotti B, Tomazzoli L, Miscusi M, et al. Gamma knife radiosurgery for brain metastases: a primary therapeutic option. J Neurosurg. 2002;97(5):515–24.

    Article  PubMed  Google Scholar 

  6. Leksell L. The stereotaxic method and radiosurgery of the brain. Acta Chir Scand. 1951;102(4):316–9.

    CAS  PubMed  Google Scholar 

  7. Skeie BS, Eide GE, Flatebo M, Heggdal JI, Larsen E, Bragstad S, et al. Quality of life is maintained using Gamma Knife radiosurgery: a prospective study of a brain metastases patient cohort. J Neurosurg. 2017;126(3):708–25.

    Article  PubMed  Google Scholar 

  8. Gaspar L, Scott C, Rotman M, Asbell S, Phillips T, Wasserman T, et al. Recursive partitioning analysis (RPA) of prognostic factors in three radiation therapy oncology group (RTOG) brain metastases trials. Int J Radiat Oncol Biol Phys. 1997;37(4):745–51.

    Article  CAS  PubMed  Google Scholar 

  9. Sperduto PW, Kased N, Roberge D, Xu Z, Shanley R, Luo X, et al. Summary report on the graded prognostic assessment: an accurate and facile diagnosis-specific tool to estimate survival for patients with brain metastases. J Clin Oncol Off J Am Soc Clin Oncol. 2012;30(4):419–25.

    Article  Google Scholar 

  10. Sperduto PW, Berkey B, Gaspar LE, Mehta M, Curran W. A new prognostic index and comparison to three other indices for patients with brain metastases: an analysis of 1,960 patients in the RTOG database. Int J Radiat Oncol Biol Phys. 2008;70(2):510–4.

    Article  PubMed  Google Scholar 

  11. Vecht CJ, Haaxma-Reiche H, Noordijk EM, Padberg GW, Voormolen JH, Hoekstra FH, et al. Treatment of single brain metastasis: radiotherapy alone or combined with neurosurgery? Ann Neurol. 1993;33(6):583–90.

    Article  CAS  PubMed  Google Scholar 

  12. Patchell RA, Tibbs PA, Walsh JW, Dempsey RJ, Maruyama Y, Kryscio RJ, et al. A randomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med. 1990;322(8):494–500.

    Article  CAS  PubMed  Google Scholar 

  13. Mintz AH, Kestle J, Rathbone MP, Gaspar L, Hugenholtz H, Fisher B, et al. A randomized trial to assess the efficacy of surgery in addition to radiotherapy in patients with a single cerebral metastasis. Cancer. 1996;78(7):1470–6.

    Article  CAS  PubMed  Google Scholar 

  14. Patchell RA, Tibbs PA, Regine WF, Dempsey RJ, Mohiuddin M, Kryscio RJ, et al. Postoperative radiotherapy in the treatment of single metastases to the brain: a randomized trial. JAMA. 1998;280(17):1485–9.

    Article  CAS  PubMed  Google Scholar 

  15. Kocher M, Soffietti R, Abacioglu U, Villa S, Fauchon F, Baumert BG, et al. Adjuvant whole-brain radiotherapy versus observation after radiosurgery or surgical resection of one to three cerebral metastases: results of the EORTC 22952-26001 study. J Clin Oncol Off J Am Soc Clin Oncol. 2011;29(2):134–41.

    Article  Google Scholar 

  16. Kondziolka D, Patel A, Lunsford LD, Kassam A, Flickinger JC. Stereotactic radiosurgery plus whole brain radiotherapy versus radiotherapy alone for patients with multiple brain metastases. Int J Radiat Oncol Biol Phys. 1999;45(2):427–34.

    Article  CAS  PubMed  Google Scholar 

  17. Andrews DW, Scott CB, Sperduto PW, Flanders AE, Gaspar LE, Schell MC, et al. Whole brain radiation therapy with or without stereotactic radiosurgery boost for patients with one to three brain metastases: phase III results of the RTOG 9508 randomised trial. Lancet. 2004;363(9422):1665–72.

    Article  PubMed  Google Scholar 

  18. Aoyama H, Shirato H, Tago M, Nakagawa K, Toyoda T, Hatano K, et al. Stereotactic radiosurgery plus whole-brain radiation therapy vs stereotactic radiosurgery alone for treatment of brain metastases: a randomized controlled trial. JAMA. 2006;295(21):2483–91.

    Article  CAS  PubMed  Google Scholar 

  19. Chang EL, Wefel JS, Hess KR, Allen PK, Lang FF, Kornguth DG, et al. Neurocognition in patients with brain metastases treated with radiosurgery or radiosurgery plus whole-brain irradiation: a randomised controlled trial. Lancet Oncol. 2009;10(11):1037–44.

    Article  PubMed  Google Scholar 

  20. Prabhu RS, Press RH, Patel KR, Boselli DM, Symanowski JT, Lankford SP, et al. Single-fraction stereotactic radiosurgery (SRS) alone versus surgical resection and SRS for large brain metastases: a multi-institutional analysis. Int J Radiat Oncol Biol Phys. 2017;99(2):459–67.

    Article  PubMed  Google Scholar 

  21. Quigley MR, Bello N, Jho D, Fuhrer R, Karlovits S, Buchinsky FJ. Estimating the additive benefit of surgical excision to stereotactic radiosurgery in the management of metastatic brain disease. Neurosurgery. 2015;76(6):707–12; discussion 12-3

    Article  PubMed  Google Scholar 

  22. Pulenzas N, Khan L, Tsao M, Zhang L, Lechner B, Thavarajah N, et al. Fatigue scores in patients with brain metastases receiving whole brain radiotherapy. Support Care Cancer. 2014;22(7):1757–63.

    Article  PubMed  Google Scholar 

  23. Aoyama H, Tago M, Kato N, Toyoda T, Kenjyo M, Hirota S, et al. Neurocognitive function of patients with brain metastasis who received either whole brain radiotherapy plus stereotactic radiosurgery or radiosurgery alone. Int J Radiat Oncol Biol Phys. 2007;68(5):1388–95.

    Article  PubMed  Google Scholar 

  24. Marchan EM, Peterson J, Sio TT, Chaichana KL, Harrell AC, Ruiz-Garcia H, et al. Postoperative cavity stereotactic radiosurgery for brain metastases. Front Oncol. 2018;8:342.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Keller A, Dore M, Cebula H, Thillays F, Proust F, Darie I, et al. Hypofractionated stereotactic radiation therapy to the resection bed for intracranial metastases. Int J Radiat Oncol Biol Phys. 2017;99(5):1179–89.

    Article  PubMed  Google Scholar 

  26. Steinmann D, Maertens B, Janssen S, Werner M, Fruhauf J, Nakamura M, et al. Hypofractionated stereotactic radiotherapy (hfSRT) after tumour resection of a single brain metastasis: report of a single-Centre individualized treatment approach. J Cancer Res Clin Oncol. 2012;138(9):1523–9.

    Article  PubMed  Google Scholar 

  27. Patel KR, Burri SH, Asher AL, Crocker IR, Fraser RW, Zhang C, et al. Comparing preoperative with postoperative stereotactic radiosurgery for Resectable brain metastases: a multi-institutional analysis. Neurosurgery. 2016;79(2):279–85.

    Article  PubMed  Google Scholar 

  28. Roberge D, Souhami L. Tumor bed radiosurgery following resection of brain metastases: a review. Technol Cancer Res Treat. 2010;9(6):597–602.

    Article  PubMed  Google Scholar 

  29. Brennan C, Yang TJ, Hilden P, Zhang Z, Chan K, Yamada Y, et al. A phase 2 trial of stereotactic radiosurgery boost after surgical resection for brain metastases. Int J Radiat Oncol Biol Phys. 2014;88(1):130–6.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Mahajan A, Ahmed S, McAleer MF, Weinberg JS, Li J, Brown P, et al. Post-operative stereotactic radiosurgery versus observation for completely resected brain metastases: a single-Centre, randomised, controlled, phase 3 trial. Lancet Oncol. 2017;18(8):1040–8.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Brown PD, Ballman KV, Cerhan JH, Anderson SK, Carrero XW, Whitton AC, et al. Postoperative stereotactic radiosurgery compared with whole brain radiotherapy for resected metastatic brain disease (NCCTG N107C/CEC.3): a multicentre, randomised, controlled, phase 3 trial. Lancet Oncol. 2017;18(8):1049–60.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Jensen CA, Chan MD, McCoy TP, Bourland JD, deGuzman AF, Ellis TL, et al. Cavity-directed radiosurgery as adjuvant therapy after resection of a brain metastasis. J Neurosurg. 2011;114(6):1585–91.

    Article  PubMed  Google Scholar 

  33. Hartford AC, Paravati AJ, Spire WJ, Li Z, Jarvis LA, Fadul CE, et al. Postoperative stereotactic radiosurgery without whole-brain radiation therapy for brain metastases: potential role of preoperative tumor size. Int J Radiat Oncol Biol Phys. 2013;85(3):650–5.

    Article  PubMed  Google Scholar 

  34. Jagannathan J, Yen CP, Ray DK, Schlesinger D, Oskouian RJ, Pouratian N, et al. Gamma Knife radiosurgery to the surgical cavity following resection of brain metastases. J Neurosurg. 2009;111(3):431–8.

    Article  PubMed  Google Scholar 

  35. Soltys SG, Adler JR, Lipani JD, Jackson PS, Choi CY, Puataweepong P, et al. Stereotactic radiosurgery of the postoperative resection cavity for brain metastases. Int J Radiat Oncol Biol Phys. 2008;70(1):187–93.

    Article  PubMed  Google Scholar 

  36. Choi CY, Chang SD, Gibbs IC, Adler JR, Harsh GR, Lieberson RE, et al. Stereotactic radiosurgery of the postoperative resection cavity for brain metastases: prospective evaluation of target margin on tumor control. Int J Radiat Oncol Biol Phys. 2012;84(2):336–42.

    Article  PubMed  Google Scholar 

  37. Soliman H, Ruschin M, Angelov L, Brown PD, Chiang VLS, Kirkpatrick JP, et al. Consensus contouring guidelines for postoperative completely resected cavity stereotactic radiosurgery for brain metastases. Int J Radiat Oncol Biol Phys. 2018;100(2):436–42.

    Article  PubMed  Google Scholar 

  38. Iorio-Morin C, Masson-Cote L, Ezahr Y, Blanchard J, Ebacher A, Mathieu D. Early Gamma Knife stereotactic radiosurgery to the tumor bed of resected brain metastasis for improved local control. J Neurosurg. 2014;121:69–74.

    Article  PubMed  Google Scholar 

  39. Patel RA, Lock D, Helenowski IB, Chandler JP, Sachdev S, Tate MC, et al. Postsurgical cavity evolution after brain metastasis resection: how soon should postoperative radiosurgery follow? World Neurosurg. 2018;110:e310–e4.

    Article  PubMed  Google Scholar 

  40. Trifiletti DM, Lee CC, Kano H, Cohen J, Janopaul-Naylor J, Alonso-Basanta M, et al. Stereotactic radiosurgery for brainstem metastases: an international cooperative study to define response and toxicity. Int J Radiat Oncol Biol Phys. 2016;96(2):280–8.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Trifiletti DM, Lee CC, Shah N, Patel NV, Chen SC, Sheehan JP. How does brainstem involvement affect prognosis in patients with limited brain metastases? Results of a matched-cohort analysis. World Neurosurg. 2016;88:563–8.

    Article  PubMed  Google Scholar 

  42. Shaw E, Scott C, Souhami L, Dinapoli R, Kline R, Loeffler J, et al. Single dose radiosurgical treatment of recurrent previously irradiated primary brain tumors and brain metastases: final report of RTOG protocol 90-05. Int J Radiat Oncol Biol Phys. 2000;47(2):291–8.

    Article  CAS  PubMed  Google Scholar 

  43. Minniti G, Clarke E, Lanzetta G, Osti MF, Trasimeni G, Bozzao A, et al. Stereotactic radiosurgery for brain metastases: analysis of outcome and risk of brain radionecrosis. Radiat Oncol. 2011;6:48.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Asher AL, Burri SH, Wiggins WF, Kelly RP, Boltes MO, Mehrlich M, et al. A new treatment paradigm: neoadjuvant radiosurgery before surgical resection of brain metastases with analysis of local tumor recurrence. Int J Radiat Oncol Biol Phys. 2014;88(4):899–906.

    Article  PubMed  Google Scholar 

  45. Patel KR, Burri SH, Boselli D, Symanowski JT, Asher AL, Sumrall A, et al. Comparing pre-operative stereotactic radiosurgery (SRS) to post-operative whole brain radiation therapy (WBRT) for resectable brain metastases: a multi-institutional analysis. J Neuro-Oncol. 2017;131(3):611–8.

    Article  CAS  Google Scholar 

  46. Bindal AK, Bindal RK, Hess KR, Shiu A, Hassenbusch SJ, Shi WM, et al. Surgery versus radiosurgery in the treatment of brain metastasis. J Neurosurg. 1996;84(5):748–54.

    Article  CAS  PubMed  Google Scholar 

  47. Muacevic A, Wowra B, Siefert A, Tonn JC, Steiger HJ, Kreth FW. Microsurgery plus whole brain irradiation versus Gamma Knife surgery alone for treatment of single metastases to the brain: a randomized controlled multicentre phase III trial. J Neuro-Oncol. 2008;87(3):299–307.

    Article  Google Scholar 

  48. Roos DE, Smith JG, Stephens SW. Radiosurgery versus surgery, both with adjuvant whole brain radiotherapy, for solitary brain metastases: a randomised controlled trial. Clin Oncol. 2011;23(9):646–51.

    Article  CAS  Google Scholar 

  49. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology (NCCN Guidelines®) - Central Nervous System Cancers 2018 updated March 20, 2018. Available from: https://www.nccn.org/professionals/physician_gls/pdf/cns.pdf.

  50. Wang TJ, Saad S, Qureshi YH, Jani A, Isaacson SR, Sisti MB, et al. Outcomes of Gamma Knife radiosurgery, bi-modality & tri-modality treatment regimens for patients with one or multiple brain metastases: the Columbia University medical center experience. J Neuro-Oncol. 2015;122(2):399–408.

    Article  CAS  Google Scholar 

  51. Aoyama H, Tago M, Shirato H. Japanese radiation oncology study group I. stereotactic radiosurgery with or without whole-brain radiotherapy for brain metastases: secondary analysis of the JROSG 99-1 randomized clinical trial. JAMA Oncol. 2015;1(4):457–64.

    Article  PubMed  Google Scholar 

  52. Churilla TM, Handorf E, Collette S, Collette L, Dong Y, Aizer AA, et al. Whole brain radiotherapy after stereotactic radiosurgery or surgical resection among patients with one to three brain metastases and favorable prognoses: a secondary analysis of EORTC 22952-26001. Ann Oncol. 2017;28(10):2588–94.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  53. ASTRO. ASTRO releases second list of five radiation oncology treatments to question, as part of national Choosing Wisely® campaign 2014. Available from: http://www.choosingwisely.org/astro-releases-second-list/.

  54. Bhatnagar AK, Flickinger JC, Kondziolka D, Lunsford LD. Stereotactic radiosurgery for four or more intracranial metastases. Int J Radiat Oncol Biol Phys. 2006;64(3):898–903.

    Article  PubMed  Google Scholar 

  55. Bhatnagar AK, Kondziolka D, Lunsford LD, Flickinger JC. Recursive partitioning analysis of prognostic factors for patients with four or more intracranial metastases treated with radiosurgery. Technol Cancer Res Treat. 2007;6(3):153–60.

    Article  CAS  PubMed  Google Scholar 

  56. Dea N, Borduas M, Kenny B, Fortin D, Mathieu D. Safety and efficacy of Gamma Knife surgery for brain metastases in eloquent locations. J Neurosurg. 2010;113:79–83.

    Article  PubMed  Google Scholar 

  57. Hsu F, Nichol A, Ma R, Kouhestani P, Toyota B, McKenzie M. Stereotactic radiosurgery for metastases in eloquent central brain locations. Can J Neurol Sci. 2015;42(5):333–7.

    Article  PubMed  Google Scholar 

  58. Trifiletti DM, Lee CC, Winardi W, Patel NV, Yen CP, Larner JM, et al. Brainstem metastases treated with stereotactic radiosurgery: safety, efficacy, and dose response. J Neuro-Oncol. 2015;125(2):385–92.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Jason P. Sheehan .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2020 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Ruiz-Garcia, H.J., Trifiletti, D.M., Sheehan, J.P. (2020). Stereotactic Radiosurgery: Indications and Outcomes in Central Nervous System and Skull Base Metastases. In: Ramakrishna, R., Magge, R., Baaj, A., Knisely, J. (eds) Central Nervous System Metastases. Springer, Cham. https://doi.org/10.1007/978-3-030-42958-4_22

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-42958-4_22

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-42957-7

  • Online ISBN: 978-3-030-42958-4

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics