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MO_6_2602 - Evolution in the Role of Stereotactic Radiosurgery in Patients with Multiple Brain Metastases: An International Survey

Monday, October 22
10:45 AM - 12:15 PM
Location: Innovation Hub, Exhibit Hall 3

Evolution in the Role of Stereotactic Radiosurgery in Patients with Multiple Brain Metastases: An International Survey
S. W. Dutta1, J. P. Sheehan2, A. Niranjan3, L. D. Lunsford4, and D. M. Trifiletti5; 1Department of Radiation Oncology, University of Virginia, Charlottesville, VA, 2Department of Neurosurgery, University of Virginia, Charlottesville, VA, 3Center for Image-guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, 4University of Pittsburgh Medical Center, Pittsburgh, PA, 5Department of Neurosurgery, Mayo Clinic, Jacksonville, FL

Purpose/Objective(s): Currently no firm consensus exists regarding the use of stereotactic radiosurgery (SRS) alone versus whole brain radiation (WBRT) +/- SRS in patients with multiple brain metastases. The International Gamma Knife Research Foundation (IGKRF) conducted a survey to review international practice patterns.

Materials/Methods: Through 2 international radiosurgery societies, clinicians who are involved in the radiosurgical management of patients with brain metastases (i.e. Neurosurgeons, Radiation Oncologists, Medical Physicists, Neuro-Oncologists, and Medical Oncologists as appropriate) were invited to complete a questionnaire. Respondents selected therapeutic options based on brief case vignettes and could select (1) SRS alone, (2) SRS with adjuvant WBRT, (3) WBRT alone, or (4) omission of upfront local radiation. Respondents were also asked what clinical factors drove their recommendation. Common histologies such as non-small cell lung cancer (NSCLC), breast cancer, and melanoma were included.

Results: A total of 71 respondents replied to the survey, 43 of whom were academic (60%). The respondents included 41 radiation oncologists (57%), 24 neurosurgeons (34%), and 6 (8%) other clinicians. The majority of respondents (87%) had 5 or more years of experience in the role of SRS. For a patient with 7 NSCLC brain metastases, all under 1 cm, and stable extracranial disease, 77% would perform SRS alone and 17% would recommend WBRT alone. For a patient with 7 or more brain metastases, the majority selected SRS alone irrespective of tumor histology (NSCLC, breast, melanoma, p > 0.5). However, neurosurgeons would more often utilize SRS alone or SRS combined with WBRT compared to radiation oncologists (p = 0.002). Key clinical factors in selecting SRS alone were KPS (82% of respondents), total volume of metastases (81%), number of metastases (80%), and less so tumor histology (42%). Sixty percent of respondents would perform SRS alone for 12 brain metastases in a melanoma patient who was also receiving immunotherapy and 49% would recommend SRS alone for a patient with 12 NSCLC metastases on a tyrosine kinase inhibitor.

Conclusion: While important clinical factors were outlined, the number of brain metastases and histology are not the only drivers in the use of SRS. Most centers with international expertise routinely use SRS for patients with oligometastatic brain disease. While 75% clinicians prefer SRS alone for up to 7 tumors, 50% would select SRS alone for up to ten tumors. Patients with small total volume of brain disease, high KPS, or who are receiving novel systemic chemotherapy or immunotherapy are often recommended to undergo SRS. Compared to radiation oncologists, neurosurgeons more often recommend SRS regardless of the number of brain metastases emphasizing the importance of additional studies that clarify the roles of SRS and WBRT in patients with oligometastatic brain disease.

Author Disclosure: S.W. Dutta: None. J.P. Sheehan: secretary; N2QOD. A. Niranjan: None. L.D. Lunsford: None. D.M. Trifiletti: Member; ARRO.

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