Neoadjuvant fractionated stereotactic radiotherapy followed by piecemeal resection of brain metastasis: a case series of 20 patients

Shoichi Deguchi,Hirofumi Asakura,Hideyuki Harada,Nakamasa Hayashi,Koichi Mitsuya,Tsuyoshi Onoe,Kazuaki Yasui,Hirofumi Ogawa,Keisuke Kimura

doi:10.1007/s10147-021-02083-8

Shoichi Deguchi, Hirofumi Asakura + Show 7 more

Open Access

https://doi.org/10.1007/s10147-021-02083-8

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Abstract

BackgroundThe safety and effectiveness of neoadjuvant fractionated stereotactic radiotherapy (FSRT) before piecemeal resection of brain metastasis (BM) remains unknown.MethodsWe retrospectively reviewed 20 consecutive patients with BM who underwent neoadjuvant FSRT followed by piecemeal resection between July 2019 and March 2021. The prescribed dose regimens were as follows: 30 Gy (n = 11) or 35 Gy (n = 9) in five fractions.ResultsThe mean follow-up duration was 7.8 months (range 2.2–22.3). The median age was 67 years (range 51–79). Fourteen patients were male. All patients were symptomatic. All tumors were located in the supratentorial compartment. The median maximum diameter and volume were 3.7 cm (range 2.6–4.9) and 17.6 cm3 (range 5.6–49.7), respectively. The median time from the end of FSRT to resection was 4 days (range 1–7). Nausea (CTCAE Grade 2) occurred in one patient and simple partial seizures (Grade 2) in two patients during radiation therapy. Gross total removal was performed in seventeen patients and sub-total removal in three patients. Postoperative complications were deterioration of paresis in two patients. Local recurrence was found in one patient (5.0%) who underwent sub-total resection at 2 months after craniotomy. Distant recurrence was found in six patients (30.0%) at a median of 6.9 months. Leptomeningeal disease recurrence was found in one patient (5.0%) at 3 months. No radiation necrosis developed.ConclusionsNeoadjuvant FSRT appears to be a safe and effective approach for patients with BM requiring piecemeal resection. A multi-institutional prospective trial is needed.

Highlights

Surgical resection plays a significant role in the management of brain metastasis (BM) for the relief of symptoms and improvement of overall survival (OS) [1–3]
Postoperative stereotactic radiosurgery (SRS) on the margin of the resection cavity is not performed in cases of en bloc tumor resection, but is often performed early in cases of piecemeal resection
fractionated stereotactic radiotherapy (FSRT) delivers a higher dose of radiation with potentially similar or lower rates of toxicity compared with single-fraction SRS, since fractionation takes radiobiological advantage of normal brain tissue repair and reoxygenation [3]

Summary

Introduction

Surgical resection plays a significant role in the management of brain metastasis (BM) for the relief of symptoms and improvement of overall survival (OS) [1–3]. Postoperative SRS has been reported to be associated with symptomatic radiation necrosis (RN) rates of 6–26% [6] and leptomeningeal disease (LMD) rates of 11–28% at 1 year [7–11]. In cases of piecemeal resection, there is a need for a new method of radiation therapy for reducing LMD and RN while maintaining adequate local control. The safety and effectiveness of neoadjuvant fractionated stereotactic radiotherapy (FSRT) before piecemeal resection of brain metastasis (BM) remains unknown. Methods We retrospectively reviewed 20 consecutive patients with BM who underwent neoadjuvant FSRT followed by piecemeal resection between July 2019 and March 2021. Local recurrence was found in one patient (5.0%) who underwent sub-total resection at 2 months after craniotomy. Conclusions Neoadjuvant FSRT appears to be a safe and effective approach for patients with BM requiring piecemeal resection.

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