title: Stereotactic radiosurgery alone for multiple brain metastases? A review of clinical and technical issues.
abstract: Over the past three decades several randomized trials have enabled evidence-based practice for patients presenting with limited brain metastases. These trials have focused on the role of surgery or stereotactic radiosurgery (SRS) with or without whole brain radiation therapy (WBRT). As a result, it is clear that local control should be optimized with surgery or SRS in patients with optimal prognostic factors presenting with up to 4 brain metastases. The routine use of adjuvant WBRT remains debatable, as although greater distant brain control rates are observed, there is no impact on survival, and modern outcomes suggest adverse effects from WBRT on patient cognition and quality of life. With dramatic technologic advances in radiation oncology facilitating the adoption of SRS into mainstream practice, the optimal management of patients with multiple brain metastases is now being put forward. Practice is evolving to SRS alone in these patients despite a lack of level 1 evidence to support a clinical departure from WBRT. The purpose of this review is to summarize the current state of the evidence for patients presenting with limited and multiple metastases, and to present an in-depth analysis of the technology and dosimetric issues specific to the treatment of multiple metastases.
authors.affiliation: Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Arjun
authors.initials: A
authors.lastname: Sahgal
authors.affiliation: Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Mark
authors.initials: M
authors.lastname: Ruschin
authors.affiliation: Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA.
authors.forename: Lijun
authors.initials: L
authors.lastname: Ma
authors.affiliation: Department of Radiation Oncology, VU University Medical Center, Amsterdam,The Netherlands.
authors.forename: Wilko
authors.initials: W
authors.lastname: Verbakel
authors.affiliation: Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA.
authors.forename: David
authors.initials: D
authors.lastname: Larson
authors.affiliation: Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA.
authors.forename: Paul D
authors.initials: PD
authors.lastname: Brown
mesh_terms: D001932:Brain Neoplasms / Q000532:radiotherapy* / Q000556:secondary*; D006801:Humans; D011788:Quality of Life; D016634:Radiosurgery / Q000379:methods*; D018714:Radiotherapy, Adjuvant / Q000009:adverse effects / Q000379:methods; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome
keywords: brain metastases; multiple metastases; radiosurgery; stereotactic radiosurgery