title: Survival was Significantly Better with Surgical/Medical/Radiation Co-interventions in a Single-Institution Practice Audit of Frameless Stereotactic Radiosurgery.
abstract: OBJECTIVE
  To audit outcomes after introducing frameless stereotactic radiosurgery (SRS) for brain metastases, including co-interventions: neurosurgery, systemic therapy, and whole brain radiotherapy (WBRT). We report median overall survival (MS), local failure, and distant brain failure. We hypothesized patients treated with SRS would have clinically meaningful improved MS compared with historic institutional values. We further hypothesized that patients treated with co-interventions would have clinically meaningful improved MS compared with patients treated with SRS alone.
  
  
  METHODS
  One hundred twenty patients (N = 120) with limited intracranial disease underwent 130 frameless SRS sessions from April 2010 to May 2013. Median follow-up was 11 months. MS was measured from brain metastases diagnosis, local failure, and distant brain failure from the time of first SRS.
  
  
  RESULTS
  Practice pattern during the first year of the study favored upfront WBRT (79%) over SRS (21%) while upfront SRS (45%) was almost as common as upfront WBRT (55%) in the last year of the study. MS was 18 months; 37% received SRS alone as initial radiotherapy (MS 12 months); 63% received WBRT prior to SRS (MS 19 months); 50% received systemic therapy post-SRS (MS 21 months); and 26% had tumor resection then SRS to the surgical cavity (MS 42 months). Local failure occurred in 10% of lesions and radio-necrosis occurred in 4%. Differences in distant brain failure among patients treated with upfront SRS (40% rate), WBRT followed by SRS (33% rate) or systemic therapy post-SRS (37% rate) were not statistically significant.
  
  
  CONCLUSIONS
  Frameless SRS effectively treats surgical cavities, persistent tumors post-WBRT, and can be used as an upfront treatment of brain metastases. Surgery, systemic therapy, and WBRT are associated with longer MS. Patients can live for years while receiving multiple therapies. Systemic therapy for patients with brain metastases is increasingly common, palliative care occurs earlier and improves survival, and WBRT use is not routine. Modern series sometimes produce unexpectedly good results. Classification and treatment protocols are evolving. This practice audit is note-worthy for (i) high median overall survival, (ii) systemic therapy after radiosurgery for patients with tumors treated by radiosurgery, (iii) distant brain failure not significantly related to WBRT, and (iv) neurosurgery, systemic therapy, and WBRT are independently associated with improved MS.
authors.affiliation: Oncology, University of Calgary.
authors.forename: Amandeep
authors.initials: A
authors.lastname: Taggar
authors.affiliation: NHS Lothian.
authors.forename: Joanna
authors.initials: J
authors.lastname: MacKenzie
authors.affiliation: Statistics, University of Calgary.
authors.forename: Haocheng
authors.initials: H
authors.lastname: Li
authors.affiliation: Radiation Oncology, Tom Baker Cancer Centre, Calgary.
authors.forename: Harold
authors.initials: H
authors.lastname: Lau
authors.affiliation: Radiation Oncology, Tom Baker Cancer Centre, Calgary.
authors.forename: Gerald
authors.initials: G
authors.lastname: Lim
authors.affiliation: Radiation Oncology, Tom Baker Cancer Centre, Calgary.
authors.forename: Robert
authors.initials: R
authors.lastname: Nordal
authors.affiliation: Medical Physics, Tom Baker Cancer Centre, Calgary.
authors.forename: Alana
authors.initials: A
authors.lastname: Hudson
authors.affiliation: Radiation Oncology, Washington University School of Medicine.
authors.forename: Rao
authors.initials: R
authors.lastname: Khan
authors.affiliation: Medical Physics, Tom Baker Cancer Centre, Calgary.
authors.forename: David
authors.initials: D
authors.lastname: Spencer
authors.affiliation: Oncology, Foothills Medical Centre.
authors.forename: Jon-Paul
authors.initials: JP
authors.lastname: Voroney
keywords: Stereotactic Radiosurgery; brain metastases; neurosurgery; systemic therapy; whole brain radiotherapy