The use of radiosurgery as a first-line or salvage treatment for brain metastases continues to expand. As a focal, highly precise treatment option, stereotactic radiosurgery (SRS) provides many benefits, including a short treatment timeline, a low probability of normal tissue complication, and a high probability of treated lesion control.1 However, with increased adoption of this approach also comes an increase in incidence of treatment failure. Radiosurgical failure, either due to tumor regrowth or radiation necrosis, can occur in about 10% to 15% of patients still alive at 1 yr.2 Management of brain metastases after radiosurgical failure depends on patient treatment history but often radiation options have been exhausted early. Traditional craniotomy remains an option for single lesion failures if the lesion is surgically accessible, surgery can be performed with minimal morbidity, and the patient remains with good functional status. For patients who have a single surgically difficult to access lesion or who have one of many lesions that may be symptomatic enough to prevent ongoing systemic cancer treatment, few options exist. Use of chemotherapy for tumor regrowth has limited success and use of immunotherapy for tumor regrowth is often complicated by the need for steroid management of symptoms. Bevacizumab and surgical resection have been shown to be effective in the treatment of radiation necrosis lesions but practically bevacizumab is often difficult to obtain due to restrictions related to FDA approval and insurance reimbursement and often lesions are deep and surgically less accessible.3-5 An alternative surgical option for these patients is laser thermal ablation (LTA) for which an increasing body of experience is being developed nationally.
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