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Preoperative stereotactic radiosurgery as neoadjuvant therapy for resectable brain tumors

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Abstract

Purpose

Stereotactic radiosurgery (SRS) is a method of delivering conformal radiation, which allows minimal radiation damage to surrounding healthy tissues. Adjuvant radiation therapy has been shown to improve local control in a variety of intracranial neoplasms, such as brain metastases, gliomas, and benign tumors (i.e., meningioma, vestibular schwannoma, etc.). For brain metastases, adjuvant SRS specifically has demonstrated positive oncologic outcomes as well as preserving cognitive function when compared to conventional whole brain radiation therapy. However, as compared with neoadjuvant SRS, larger post-operative volumes and greater target volume uncertainty may come with an increased risk of local failure and treatment-related complications, such as radiation necrosis. In addition to its role in brain metastases, neoadjuvant SRS for high grade gliomas may enable dose escalation and increase immunogenic effects and serve a purpose in benign tumors for which one cannot achieve a gross total resection (GTR). Finally, although neoadjuvant SRS has historically been delivered with photon therapy, there are high LET radiation modalities such as carbon-ion therapy which may allow radiation damage to tissue and should be further studied if done in the neoadjuvant setting. In this review we discuss the evolving role of neoadjuvant radiosurgery in the treatment for brain metastases, gliomas, and benign etiologies. We also offer perspective on the evolving role of high LET radiation such as carbon-ion therapy.

Methods

PubMed was systemically reviewed using the search terms “neoadjuvant radiosurgery”, “brain metastasis”, and “glioma”. ‘Clinicaltrials.gov’ was also reviewed to include ongoing phase III trials.

Results

This comprehensive review describes the evolving role for neoadjuvant SRS in the treatment for brain metastases, gliomas, and benign etiologies. We also discuss the potential role for high LET radiation in this setting such as carbon-ion radiotherapy.

Conclusion

Early clinical data is very promising for neoadjuvant SRS in the setting of brain metastases. There are three ongoing phase III trials that will be more definitive in evaluating the potential benefits. While there is less data available for neoadjuvant SRS for gliomas, there remains a potential role, particularly to enable dose escalation and increase immunogenic effects.

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Authors and Affiliations

  1. Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA

    David Crompton, Daniel Koffler & Daniel M. Trifiletti

  2. Department of Radiation Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, USA

    Fatemeh Fekrmandi

  3. Department of Radiation Oncology, Mayo Clinic, Rochester, USA

    Eric J. Lehrer

  4. Department of Neurological Surgery, University of Virginia, Charlottesville, USA

    Jason P. Sheehan

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  1. David Crompton
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  2. Daniel Koffler
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  3. Fatemeh Fekrmandi
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  4. Eric J. Lehrer
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  5. Jason P. Sheehan
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Contributions

DC wrote the abstract, section on brain metastases, benign intracranial neoplasms, and conclusion. DK wrote the section on high LET. FF wrote the section on gliomas. All authors reviewed all sections of the review.

Corresponding author

Correspondence to Daniel M. Trifiletti.

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Competing interests

Dr. Trifiletti reports publishing fees from Springer Inc. as he reported on our Title Page.

Conflict of interest

Dr. Trifiletti reports clinical trial research support from the Florida Department of Health, Varian Medical Systems, Novocure, and Blue Earth Diagnostics Ltd., publishing fees from Springer Inc., as well as consulting fees from Boston Scientific Corporation. None of the other authors have relevant conflicts of interest.

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Crompton, D., Koffler, D., Fekrmandi, F. et al. Preoperative stereotactic radiosurgery as neoadjuvant therapy for resectable brain tumors. J Neurooncol 165, 21–28 (2023). https://doi.org/10.1007/s11060-023-04466-5

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