title: Indications and Efficacy of Gamma Knife Stereotactic Radiosurgery for Recurrent Glioblastoma: 2 Decades of Institutional Experience.
abstract: The role of stereotactic radiosurgery (SRS) for recurrent glioblastoma and the radionecrosis risk in this setting remain unclear.
  
  
  
  To perform a large retrospective study to help inform proper indications, efficacy, and anticipated complications of SRS for recurrent glioblastoma.
  
  
  
  We retrospectively analyzed patients who underwent Gamma Knife SRS between 1991 and 2013. We used the partitioning deletion/substitution/addition algorithm to identify potential predictor covariate cut points and Kaplan-Meier and proportional hazards modeling to identify factors associated with post-SRS and postdiagnosis survival.
  
  
  
  One hundred seventy-four glioblastoma patients (median age, 54.1 years) underwent SRS a median of 8.7 months after initial diagnosis. Seventy-five percent had 1 treatment target (range, 1-6), and median target volume and prescriptions were 7.0 cm 3 (range, 0.3-39.0 cm 3 ) and 16.0 Gy (range, 10-22 Gy), respectively. Median overall survival was 10.6 months after SRS and 19.1 months after diagnosis. Kaplan-Meier and multivariable modeling revealed that younger age at SRS, higher prescription dose, and longer interval between original surgery and SRS are significantly associated with improved post-SRS survival. Forty-six patients (26%) underwent salvage craniotomy after SRS, with 63% showing radionecrosis or mixed tumor/necrosis vs 35% showing purely recurrent tumor. The necrosis/mixed group had lower mean isodose prescription compared with the tumor group (16.2 vs 17.8 Gy; P = .003) and larger mean treatment volume (10.0 vs 5.4 cm 3 ; P = .009).
  
  
  
  Gamma Knife may benefit a subset of focally recurrent patients, particularly those who are younger with smaller recurrences. Higher prescriptions are associated with improved post-SRS survival and do not seem to have greater risk of symptomatic treatment effect.
authors.affiliation: University of California, San Francisco School of Medicine, San Francisco, California.
authors.forename: Brandon S
authors.initials: BS
authors.lastname: Imber
authors.affiliation: Department of Neurological Surgery and.
authors.forename: Ishan
authors.initials: I
authors.lastname: Kanungo
authors.affiliation: Department of Radiation Oncology, University of California, San Francisco, San Francisco, California.
authors.forename: Steve
authors.initials: S
authors.lastname: Braunstein
authors.affiliation: Department of Radiation Oncology, University of California, San Francisco, San Francisco, California.
authors.forename: Igor J
authors.initials: IJ
authors.lastname: Barani
authors.affiliation: Department of Radiation Oncology, University of California, San Francisco, San Francisco, California.
authors.forename: Shannon E
authors.initials: SE
authors.lastname: Fogh
authors.affiliation: Department of Radiation Oncology, University of California, San Francisco, San Francisco, California.
authors.forename: Jean L
authors.initials: JL
authors.lastname: Nakamura
authors.affiliation: Department of Neurological Surgery and.
authors.forename: Mitchel S
authors.initials: MS
authors.lastname: Berger
authors.affiliation: Department of Neurological Surgery and.
authors.forename: Edward F
authors.initials: EF
authors.lastname: Chang
authors.affiliation: Department of Neurological Surgery and.
authors.forename: Annette M
authors.initials: AM
authors.lastname: Molinaro
authors.affiliation: Department of Neurological Surgery and.
authors.forename: Juan R
authors.initials: JR
authors.lastname: Cabrera
authors.affiliation: Department of Neurological Surgery and.
authors.forename: Michael W
authors.initials: MW
authors.lastname: McDermott
authors.affiliation: Department of Radiation Oncology, University of California, San Francisco, San Francisco, California.
authors.forename: Penny K
authors.initials: PK
authors.lastname: Sneed
authors.affiliation: Department of Neurological Surgery and.
authors.forename: Manish K
authors.initials: MK
authors.lastname: Aghi
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001932:Brain Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D003399:Craniotomy; D005260:Female; D005909:Glioblastoma / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016634:Radiosurgery; D012189:Retrospective Studies; D016879:Salvage Therapy; D016896:Treatment Outcome; D055815:Young Adult
keywords: Gamma knife; Glioblastoma; Radionecrosis; Recurrent; SRS; Stereotactic radiosurgery