title: Initial clinical experience with frameless radiosurgery for patients with intracranial metastases.
abstract: OBJECTIVE
  To review the initial clinical experience with frameless stereotactic radiosurgery (SRS) for treating intracranial metastatic disease.
  
  
  METHODS
  Sixty-four patients received frameless SRS for intracranial metastatic disease. Minimum follow-up was 6 months with none lost to follow-up. Patients had a median of 2 metastases and a maximum of 4. The median number of isocenters was 2 with median arcs of 10 and median dose of 17.5 Gy. Thirteen patients were treated for progressive/recurrent disease after surgical resection or whole brain radiotherapy (WBRT). Fifty-one patients were treated with frameless SRS as an an adjunct to initial treatment. Of the total treated, 17 were treated with SRS alone, 20 were treated with WBRT plus SRS, 16 were treated with surgical resection plus SRS, and the remaining 11 were treated with surgical resection plus WBRT plus SRS.
  
  
  RESULTS
  With a median actuarial follow-up period of 8.2 months, ultimate local control was 88%. The median time to progression was 8.1 months. The median overall survival was 8.7 months. Of the 17 patients treated with SRS alone, 86% had ultimate local control with mean overall survival of 7.1 months. Of the 13 patients who received surgical resection plus SRS without WBRT as primary treatment, there was 85% ultimate local control with an overall survival of 10.3 months. Three patients treated with initial surgery alone had recurrence treated with SRS 2-3 months after resection. All these patients obtained local control and median survival was >10 months. Of the 13 patients who received WBRT followed by SRS as boost treatment, 92% had local control and mean overall survival was 7.3 months. Of 7 patients who received SRS after recurrence after WBRT, 100% had local control with median survival of 8.2 months. For 8 patients who received surgery followed by WBRT and SRS, local control was 50%; however, ultimate intracranial control was achieved in 7 of 8 patients with repeat SRS and surgical resection. The overall survival in this group of patients was 14.7 months. No patient had a serious (Grade 3 or higher) complication requiring intervention.
  
  
  CONCLUSIONS
  Frameless optically guided radiosurgery is less invasive, can be performed as a standard radiotherapy-based simulation procedure, and maintains submillimetric accuracy. Our initial results with frameless SRS for metastatic disease suggest survival times and local control (88%) eqiuvalent to frame-based methodologies. Practical noninvasive delivery makes treatment and potential retreatment to avoid WBRT more feasible.
authors.affiliation: Department of Radiation Oncology, University of Iowa College of Medicine, Iowa City, IA, USA.
authors.forename: Reena
authors.initials: R
authors.lastname: Kamath
authors.forename: Timothy C
authors.initials: TC
authors.lastname: Ryken
authors.forename: Sanford L
authors.initials: SL
authors.lastname: Meeks
authors.forename: Edward C
authors.initials: EC
authors.lastname: Pennington
authors.forename: Justine
authors.initials: J
authors.lastname: Ritchie
authors.forename: John M
authors.initials: JM
authors.lastname: Buatti
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001932:Brain Neoplasms / Q000401:mortality / Q000556:secondary* / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016634:Radiosurgery / Q000295:instrumentation / Q000379:methods*; D016019:Survival Analysis