title: Repeat Courses of Stereotactic Radiosurgery (SRS), Deferring Whole-Brain Irradiation, for New Brain Metastases After Initial SRS.
abstract: OBJECTIVE
  To report the outcomes of repeat stereotactic radiosurgery (SRS), deferring whole-brain radiation therapy (WBRT), for distant intracranial recurrences and identify factors associated with prolonged overall survival (OS).
  
  
  METHODS
  We retrospectively identified 652 metastases in 95 patients treated with 2 or more courses of SRS for brain metastases, deferring WBRT. Cox regression analyzed factors predictive for OS.
  
  
  RESULTS
  Patients had a median of 2 metastases (range, 1-14) treated per course, with a median of 2 courses (range, 2-14) of SRS per patient. With a median follow-up after first SRS of 15 months (range, 3-98 months), the median OS from the time of the first and second course of SRS was 18 (95% confidence interval [CI] 15-24) and 11 months (95% CI 6-17), respectively. On multivariate analysis, histology, graded prognostic assessment score, aggregate tumor volume (but not number of metastases), and performance status correlated with OS. The 1-year cumulative incidence, with death as a competing risk, of local failure was 5% (95% CI 4-8%). Eighteen (24%) of 75 deaths were from neurologic causes. Nineteen patients (20%) eventually received WBRT. Adverse radiation events developed in 2% of SRS sites.
  
  
  CONCLUSIONS
  Multiple courses of SRS, deferring WBRT, for distant brain metastases after initial SRS, seem to be a safe and effective approach. The graded prognostic assessment score, updated at each course, and aggregate tumor volume may help select patients in whom the deferral of WBRT might be most beneficial.
authors.affiliation: Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California.
authors.forename: David B
authors.initials: DB
authors.lastname: Shultz
authors.affiliation: Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California.
authors.forename: Leslie A
authors.initials: LA
authors.lastname: Modlin
authors.affiliation: Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California.
authors.forename: Priya
authors.initials: P
authors.lastname: Jayachandran
authors.affiliation: Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California.
authors.forename: Rie
authors.initials: R
authors.lastname: Von Eyben
authors.affiliation: Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California.
authors.forename: Iris C
authors.initials: IC
authors.lastname: Gibbs
authors.affiliation: Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Department of Radiation Oncology, Santa Clara Valley Medical Center, San Jose, California.
authors.forename: Clara Y H
authors.initials: CYH
authors.lastname: Choi
authors.affiliation: Department of Neurosurgery, Stanford University School of Medicine, Stanford, California.
authors.forename: Steven D
authors.initials: SD
authors.lastname: Chang
authors.affiliation: Department of Neurosurgery, Stanford University School of Medicine, Stanford, California.
authors.forename: Griffith R
authors.initials: GR
authors.lastname: Harsh
authors.affiliation: Department of Neurosurgery, Stanford University School of Medicine, Stanford, California.
authors.forename: Gordon
authors.initials: G
authors.lastname: Li
authors.affiliation: Department of Neurosurgery, Stanford University School of Medicine, Stanford, California.
authors.forename: John R
authors.initials: JR
authors.lastname: Adler
authors.affiliation: Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California.
authors.forename: Steven L
authors.initials: SL
authors.lastname: Hancock
authors.affiliation: Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California. Electronic address: sgsoltys@stanford.edu.
authors.forename: Scott G
authors.initials: SG
authors.lastname: Soltys
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001932:Brain Neoplasms / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy / Q000556:secondary* / Q000601:surgery*; D016371:Cranial Irradiation / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016016:Proportional Hazards Models; D016634:Radiosurgery / Q000379:methods* / Q000401:mortality; D011879:Radiotherapy Dosage; D019233:Retreatment / Q000379:methods; D012189:Retrospective Studies; D016896:Treatment Outcome; D047368:Tumor Burden; D055815:Young Adult