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Pre-operative Stereotactic Radiosurgery for Cerebral Metastatic Disease: A Retrospective Dose-Volume Study

      Highlights:

      • Neoadjuvant SRS is associated with decreased radiation dosage and improved conformality profile due to enhanced target delineation.
      • Pre-operative SRS can decrease delivery of radiation to important structures such as optic apparatus, hippocampal cortex and brain stem.
      • These findings better characterize the role of neoadjuvant SRS in brain metastatic disease and could support further clinical trials.

      Abstract

      Background and purpose

      Stereotactic radiosurgery (SRS) after maximal safe resection is an accepted treatment strategy for patients with cerebral metastatic disease. Despite its high conformality profile, the incidence of radionecrosis (RN) remains high. SRS delivered pre-operatively could be associated with a reduced incidence of RN. We sought to evaluate whether neoadjuvant SRS could reduce radiotherapy doses in a cohort of patients treated with post-operative SRS.

      Methods

      A cohort of 47 brain metastases (BM) treated at 2 academic institutions was retrospectively analyzed. Subjects underwent surgical extirpation of BMs and subsequent SRS to surgical bed. Post-operative volumetric and dosimetric data was collected from records or recreations of delivered plans; pre-operative data were derived from hypothetical radiotherapy courses and compared using Wilcoxon signed-rank tests.

      Results

      Higher planned tumor volume post-operatively (median[IQR] 12.28 [6.54, 18.69]cc vs. 10.20 [4.53, 21.70]cc respectively, p=0.4150) was observed. The median prescribed radiotherapy dose (DRx) was 16Gy pre-operatively and 24Gy post-operatively(p<0.0001). Further investigations revealed improved pre-operative conformity index (1.23[1.20, 1.29] vs. 1.29[1.23, 1.39], p=0.0098) and gradient index (2.72[2.59, 2.98] vs. 2.94[2.69, 3.47], p=0.0004). A significant difference was found in normal brain tissue exposed to 10Gy (12.97[6.78, 25.54]cc vs. 32.13[19.42, 48.40]cc, p<0.0001), 12Gy (9.31[4.56, 17.43]cc vs. 23.80[14.74, 36.56]cc, p<0.0001), and 14Gy (5.62[3.23, 11.61]cc vs. 17.47[9.00, 28.31]cc, p<0.0001), favoring pre-operative SRS.

      Conclusions

      Neoadjuvant SRS is associated reduced DRx, better conformality profile and decreased radiation to normal tissue. These findings could support the use of neoadjuvant SRS for the treatment of BMs.

      Keywords

      Abbreviations:

      BM (brain metastasis), DRx (prescribed radiation dosage), GTV (gross tumor volume), NBT (normal brain tissue), PostSRS (post-operative stereotactic radiosurgery), PreSRS (pre-operative stereotactic radiosurgery), PTV (planned tumor volume), RN (radionecrosis), SRS (stereotactic radiosurgery)
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