Advance Access: Three or More Courses of Stereotactic Radiosurgery for Patients with Multiply Recurrent Brain Metastases

Approximately 20% to 40% of patients with systemic cancer will develop brain metastases during the course of their disease.1 Treatment options include whole-brain radiation therapy (WBRT), primary stereotactic radiosurgery (SRS), surgery, or a combination of these modalities. Randomized controlled trials in patients with limited (1-3) brain metastases have demonstrated that the addition of WBRT to primary SRS is associated with measureable declines in cognitive function, including immediate recall, memory, and verbal fluency.2,3 Taken together, these studies have led to a recent change in management guidelines and consensus statements. For example, the National Comprehensive Cancer Network has recently recommended primary WBRT or SRS for patients with multiple (>3) brain metastases, and the American Society for Radiation Oncology (ASTRO) has supported the use of SRS alone in patients with multiple brain metastases and a good prognosis.1

One caveat of treatment with a local modality alone in the upfront setting is the subsequent risk for distant intracranial failure.4 With improvements in systemic therapies for primary cancers, intracranial failures will become an increasing concern. Limited experience exists regarding aggressive management of intracranial failures throughout a patient’s disease course with multiple courses of SRS with or without WBRT. In this report, we describe the natural history, intracranial recurrence patterns, quality of life (QOL) measures, and salvage therapies for patients who were treated with multiple (≥3) courses of SRS for multiply recurrent brain metastases.

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