title: Postoperative stereotactic radiosurgery to the resection cavity for large brain metastases: clinical outcomes, predictors of intracranial failure, and implications for optimal patient selection.
abstract: BACKGROUND
  Postoperative stereotactic radiosurgery for brain metastases potentially offers similar local control rates and fewer long-term neurocognitive sequelae compared to whole brain radiation therapy, although patients remain at risk for distant brain failure (DBF).
  
  
  OBJECTIVE
  To describe clinical outcomes of adjuvant stereotactic radiosurgery for large brain metastases and identify predictors of intracranial failure and their implications on optimal patient selection criteria.
  
  
  METHODS
  We performed a retrospective review on 100 large (>3 cm) brain metastases in 99 patients managed by resection followed by postoperative stereotactic radiosurgery to a median dose of 22 Gy (range, 10-28) in 1 to 5 fractions (median, 3). Primary histology was nonsmall cell lung in 40%, breast cancer in 18%, and melanoma in 17%. Forty (40%) patients had uncontrolled systemic disease.
  
  
  RESULTS
  With a median follow-up of 12.2 months (range, 0.6-87.4), the 1-year Kaplan-Meier local control was 72%, DBF 64%, and overall survival 55%. Nine patients (9%) developed evidence of radiation injury, and 6 (6%) developed leptomeningeal disease. Uncontrolled systemic disease (P=.03), melanoma histology (P=.04), and increasing number of brain metastases (P<.001) were significant predictors of DBF on Cox multivariate analysis. Patients with <4 metastases, controlled systemic disease, and nonmelanoma primary (n=47) had a 1-year DBF of 48.6% vs 80.1% for all others (P=.01).
  
  
  CONCLUSIONS
  Postoperative stereotactic radiosurgery to the resection cavity safely and effectively augments local control of large brain metastases. Patients with <4 metastases and controlled systemic disease have significantly lower rates of DBF and are ideal treatment candidates.
authors.affiliation: *Department of Radiation Oncology, University of Pittsburgh Cancer Institute, and ‡Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Diane C
authors.initials: DC
authors.lastname: Ling
authors.forename: John A
authors.initials: JA
authors.lastname: Vargo
authors.forename: Rodney E
authors.initials: RE
authors.lastname: Wegner
authors.forename: John C
authors.initials: JC
authors.lastname: Flickinger
authors.forename: Steven A
authors.initials: SA
authors.lastname: Burton
authors.forename: Johnathan
authors.initials: J
authors.lastname: Engh
authors.forename: Nduka
authors.initials: N
authors.lastname: Amankulor
authors.forename: Annette E
authors.initials: AE
authors.lastname: Quinn
authors.forename: Cihat
authors.initials: C
authors.lastname: Ozhasoglu
authors.forename: Dwight E
authors.initials: DE
authors.lastname: Heron
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; D015999:Multivariate Analysis; D011184:Postoperative Period; D016634:Radiosurgery / Q000379:methods* / Q000401:mortality; D012189:Retrospective Studies