Salvage Salvage Stereotactic Radiosurgery Research Articles

Gamma knife radiosurgery following whole-brain radiation

In this study, we aimed to determine outcomes for patients requiring salvage stereotactic radiosurgery (SRS) who have progression of brain metastatic disease after initial treatment with whole-brain radiation (WBRT). This is a retrospective analysis of a prospective database of 112 patients who were treated with salvage SRS after experiencing failure following WBRT treatment with salvage SRS. Collectively, the patients had a median overall survival of 7 months after salvage SRS. Patients who had more than two brain metastases had a significantly shorter median survival but were not subjected to increased risk for distant brain failure. We also found that a short intervening time between WBRT and central nervous system (CNS) failure did not seem to worsen the nervous system control or reduce patient survival. Small cell lung cancer (SCLC) was associated with decreased overall survival and CNS control. In conclusion, SRS use following WBRT is safe and effective in the majority of patients. Patients with rapid failure after WBRT can be successfully salvaged with SRS. The findings also shed light on the overall poor outcomes, coupled with low median survival and high rates of CNS failure, in patients suffering multiple metastases stemming from SCLC.

Automated Detection, Segmentation, and Tracking of Brain Metastases in Repeated Courses of Stereotactic Radiosurgery Using Integrated Artificial Intelligence.

Salvage stereotactic radiosurgery (SRS) for distant brain metastases has been demonstrated as a safe and effective approach for intracranial recurrences after initial SRS. However, accurate tumor detection and segmentation among responding tumors within the irradiated parenchyma can be challenging. The requirement for the registration and reference to the previous course of SRS is very time-consuming and suffers significant inter and intra-reader variability. Artificial intelligence (AI)-assisted system has been proven to improve the accuracy and efficiency in the clinical flow of de-novo SRS. We hypothesize that an integrated AI system can facilitate an automated tumor contouring process for repeated SRS. Three patients who underwent their third course of SRS to brain metastases were selected for the pioneering works. They have had two sessions of SRS with a mean lesion number of 4 and 3.7, respectively. VBrain, an FDA-approved brain tumor management AI platform, was used to co-registered serial MR scans and automatically identify, track, and contour brain metastases for each course of SRS. The AI also indicated new lesions and treated lesions for each course. Three radiation oncologists experienced in brain SRS contoured the gross tumor volumes (GTVs) of the third course of SRS in two reader modes (assisted then unassisted) with a memory washout period of one week between each section. The segmentation ground truth was established through consensus among the three experts. Lesion-wise sensitivity, contouring accuracy, and consuming time were compared between the two contouring modes. In each patient, there were 15, 11, and 9 metastases, with a median diameter of 4.72 (95% CI: 4.05, 6.91) mm. The mean lesion-wise sensitivity was 96.96±2.47% with AI assistance and 76.90 ± 7.10% without assistance. There were two false-positive lesions in the assisted read, resulting in a low average false-positive rate of 0.67 per patient, while no false positive for the unassisted mode. AI assistance improved contouring accuracy. The median Dice similarity coefficient (DSC) was 0.71 (95% CI: 0.55, 0.87) for assisted contouring and 0.65 (95% CI: 0.46, 0.85) for unassisted contouring. We also use average Hausdorff distance (HD) to measure segmentation results. The mean HD was 0.72± 0.13 mm versus 0.73±0.08 mm for the two contouring modes (p = 0.02) Furthermore, the median contouring time per case was significantly shorter with AI assistance than without assistance (20.8 minutes vs. 29.8 minutes; p < 0.001), corresponding to a 43.2% time-saving. Our results suggest that the integration of an AI-based system into repeated brain SRS can significantly improve the accuracy and efficiency of tumor detection and segmentation. This approach has the potential to streamline the treatment planning process for salvage SRS.

Radiosurgery outcomes in infratentorial juvenile pilocytic astrocytomas.

To assess survival and neurological outcomes for patients who underwent primary or salvage stereotactic radiosurgery (SRS) for infratentorial juvenile pilocytic astrocytomas (JPA). Between 1987 and 2022, 44 patients underwent SRS for infratentorial JPA. Twelve patients underwent primary SRS and 32 patients underwent salvage SRS. The median patient age at SRS was 11.6years (range, 2-84years). Prior to SRS, 32 patients had symptomatic neurological deficits, with ataxia as the most common symptom in 16 patients. The median tumor volume was 3.22cc (range, 0.16-26.6cc) and the median margin dose was 14Gy (range, 9.6-20Gy). The median follow-up was 10.9years (range, 0.42-26.58years). Overall survival (OS) after SRS was 97.7% at 1-year, and 92.5% at 5- and 10-years. Progression free survival (PFS) after SRS was 95.4% at 1-year, 79.0% at 5-years, and 61.4% at 10-years. There is not a significant difference in PFS between primary and salvage SRS patients (p = 0.79). Younger age correlated with improved PFS (HR 0.28, 95% CI 0.063-1.29, p = 0.021). Sixteen patients (50%) had symptomatic improvements while 4 patients (15.6%) had delayed onset of new symptoms related to tumor progression (n = 2) or treatment related complications (n = 2). Tumor volumetric regression or disappearance after radiosurgery was found in 24 patients (54.4%). Twelve patients (27.3%) had delayed tumor progression after SRS. Additional management of tumor progression included repeat surgery, repeat SRS, and chemotherapy. SRS was a valuable alternative to initial or repeat resection for deep seated infratentorial JPA patients. We found no survival differences between patients who had primary and salvage SRS.

Transient Subacute Facial Nerve Dysfunction After Dual Modality Treatment of Large Vestibular Schwannomas.

1: Describe subacute facial nerve paralysis after salvage stereotactic radiosurgery (SRS). 2: To analyze predictors of facial nerve weakness after dual modality treatment. Adult patients with Vestibular Schwannoma who underwent sub-total resection (STR) followed by salvage radiation. Microsurgical resection of VS, stereotactic radiosurgery, intensity-modulated radiotherapy, proton radiotherapy. Serial facial nerve function (House-Brackmann scale). Thirteen patients who underwent dual modality treatment for large VS were included (mean age = 43.6 years, 77% females). The mean pre-operative tumor volume was 11.7 cm3 (SD = 6.5) and the immediate mean post-operative remnant volume was 1.5 cm3 (SD = 1.4) with a mean extent of resection of 86.7% (SD = 9.5). The mean salvage-free interval was 20.8 months (SD = 13.3). All patients had excellent one-year FN outcome (HB grade 1, 2) after resection. Three patients developed subacute facial nerve weakness after salvage SRS (4.2-9.4 months after SRS). This paralysis responded to high dose systemic steroids and no surgical interventions for facial rehabilitation were required. At last follow up (mean 61.6 months, SD = 28.5), facial nerve function was favorable (HB grade 1-2 in 12 patients and HB grade 3 in 1 patient). There were no significant associations between various predictors and subacute deterioration of facial nerve function after SRS. Sub-acute transient facial nerve dysfunction can develop infrequently over a variable time frame after post-operative salvage SRS and usually responds to steroids. Patients should be adequately counseled about potential of transient deterioration of facial nerve function after salvage SRS.

Salvage Stereotactic Radiosurgery in Breast Cancer Patients with Multiple Brain Metastases

The overall survival rates for breast cancer are increasing due to controlled brain disease and improved systemic treatments. This study examined neurologic outcomes, tumor control, and survival data in breast cancer patients with multiple brain metastases and who required salvage stereotactic radiosurgery (SRS) for recurrent breast cancer brain metastases. The study included 231 patients with a primary diagnosis of breast cancer who underwent SRS for more than 1 brain metastases from May 1993 and July 2007. Survival analyses via univariate and multivariate Cox regression demonstrated interactions between survival and predictor values including Karnofsky Performance Scale, Recursive Partitioning Analysis Class, number of brain metastases, whole-brain radiotherapy (WBRT), immunotherapy, and chemotherapy. Of the 231 patients, the survival rate was 53% at 1 year and 26% at 5 years from initial SRS. Controlled systemic disease, adjuvant chemotherapy, and Recursive Partitioning Analysis class II were significant predictors of increased survival, while WBRT was a significant predictor of decreased survival. The median survival in patients who received WBRT after SRS was 11 months versus 23 months in those who did not. The local tumor control rate at initial follow-up was 95%. Of these, 40% of patients underwent additional brain SRS. Following salvage SRS, 8% of patients developed symptomatic adverse radiation events; however, the development of symptomatic adverse radiation events had no effect on patient survival. This report indicated that both initial and salvage SRS procedures in breast cancer patients with multiple brain metastases are effective for local control of intracranial disease while minimizing adverse radiation effects.

Salvage stereotactic radiosurgery for recurrent gliomas with prior radiation therapy.

This study aims to assess the viability of salvage stereotactic radiosurgery (SRS) for recurrent malignant gliomas through assessing overall survival, local control and toxicity.We performed a retrospective review of 65patients with 76 lesions (55 high-grade, 21 low-grade) treated with salvage SRS between 2002and 2012.Median follow-up from salvage SRS was 14.9months (IQR: 0.9-28.1), 8.3months (IQR: 4.0-13.3) and 8.5months (IQR: 3.9-15.8) for low-grade, high-grade, and combined, respectively. A 12-month overall survival from salvage SRS was 68.4, 38.7 and 47.3% for low-grade, high-grade and combined respectively. A total of 6-month local control was 86.2, 53.8 and 65.3% for low-grade, high-grade and combined, respectively.Our results indicate salvage SRS can provide acceptable survival and local control with minimal toxicity.

Long-term Outcomes after Salvage Stereotactic Radiosurgery (SRS) following In-Field Failure of Initial SRS for Brain Metastases

The optimal treatment strategy following local recurrence after stereotactic radiosurgery (SRS) remains unclear. While upfront SRS has been extensively studied, few reports focus on outcomes after retreatment. Here, we report the results following a second course of SRS for local recurrence of brain metastases previously treated with SRS. Using institutional database, patients who received salvage SRS (SRS2) following in-field failure of initial SRS (SRS1) for brain metastases were identified. Radionecrosis and local failure were defined radiographically by MRI following SRS2. The primary endpoint was defined as the time from SRS2 to the date of all-cause death or last follow-up [overall survival (OS)]. The secondary endpoints included local failure-free survival (LFFS) and radionecrosis-free survival, defined as the time from SRS2 to the date of local failure or radionecrosis, or last follow-up, respectively. Twenty-eight patients with 32 brain metastases were evaluated between years 2004 and 2015. The median interval between SRS1 and SRS2 was 9.7 months. Median OS was 22.0 months. Median LFFS time after SRS2 was 13.6 months. The overall local control rate following SRS2 was 84.4%. The 1- and 2-year local control rates are 88.3% (95% CI, 76.7-100%) and 80.3% (95% CI, 63.5-100%), respectively. The overall rate of radionecrosis following SRS2 was 18.8%. On univariate analysis, higher prescribed isodose line (p = 0.033) and higher gross tumor volume (p = 0.015) at SRS1 were associated with radionecrosis. Although not statistically significant, there was a trend toward lower risk of radionecrosis with interval surgical resection, fractionated SRS, lower total EQD2 (<50 Gy), and lack of concurrent systemic therapy at SRS2. In select patients, repeat LINAC-based SRS following recurrence remains a reasonable option leading to long-term survival and local control. Radionecrosis approaches 20% for high risk individuals and parallels historic values.

322 Rate of Residual Tumor Growth After Primary Subtotal Resection (STR) and the Role of Upfront Versus Salvage Stereotactic Radiosurgery (SRS) for Sporadic Vestibular Schwannomas

Abstract INTRODUCTION Maximal safe resection is an optimal surgical strategy for moderate-to-large vestibular schwannomas, however data on the long-term outcomes of residual tumor after STR is lacking. The goal of this study was to review our rates of residual tumor growth, and the control rates of salvage versus upfront stereotactic radiosurgery (SRS). METHODS This retrospective single-institution study included all sporadic vestibular schwannomas treated primarily with STR at our institution from 2002 2015. The primary outcome was tumor growth requiring salvage treatment, and response to salvage treatment (surgery or SRS). Patients treated with upfront SRS after surgery were analyzed separately. RESULTS &gt;295 patients underwent primary surgery for a vestibular schwannoma between 2002 - 2015, including 140 STRs. 49 cases with &lt;1 year follow-up were excluded. 17 cases received upfront SRS after surgery (12 Gamma Knife, 12Gy; 5 CyberKnife, 25Gy in 5 fractions), with 2 failures requiring salvage surgery at 1.6 and 2.6 years (88% control rate at 1.8 years). Seventy-four residual tumors were managed with observation after STR. 57 (77%) remained stable at a median 4.1 years. 17 tumors (23%) progressed, requiring salvage treatment at a median of 2.8 years. Eleven received Gamma Knife (12.5 Gy) with a 100% control rate 2.3 years after SRS. One received Cyber Knife (18Gy, 3 fractions), ultimately requiring repeat surgery 3 years later. 4 residual tumors received salvage surgery at a median interval of 5 years after STR, and one was lost to follow-up. The control rate of salvage SRS was 92% at 2.3 years median follow-up. CONCLUSION A majority (77%) of residual vestibular schwannomas remained stable after a primary STR. Both upfront and salvage SRS had good control rates (∼90%) in our series. Further study is needed to define the role of upfront versus salvage SRS after a primary STR.

JCOG0504: A phase III randomized trial of surgery with whole brain radiation therapy versus surgery with salvage stereotactic radiosurgery in patients with 1 to 4 brain metastases.

2003Background: Whether salvage stereotactic radiosurgery (SRS) alone is effective for patients with brain metastases (BM) is not yet clarified, although clinical benefits such as better preservation of cognitive function and a shorter treatment period are reported with SRS compared to whole-brain radiation therapy (WBRT). We conducted a non-inferiority, randomized study of the effectiveness of salvage SRS for residual and recurrent tumors after surgical resection in comparison to tumor resection plus WBRT. Methods: Patients between 20-79 years with ECOG performance status (PS) 0-3 and ≤4 BM with only one lesion ≥3 cm in diameter having been surgically resected were eligible. Within 21 days after surgery, patients were randomized to WBRT or salvage SRS for residual and recurrent tumors. The primary end point was overall survival (OS) and the secondary end points were intracranial progression-free survival (IC-PFS), adverse events, and proportion of non-worsening in PS and Mini Mental Status Examination (M...

Salvage stereotactic radiosurgery for recurrent glioblastoma multiforme with prior radiation therapy.

Glioblastoma multiforme (GBM) carries a poor prognosis with high recurrence rates. Salvage stereotactic radiosurgery (SRS) may be an effective treatment option. We retrospectively reviewed 34 patients (41 lesions) treated with salvage SRS for recurrent GBM between 2004 and 2012. Initial surgical treatments were gross total resection (58%), subtotal resection (STR) (24%), and biopsy (18%). All patients were treated with prior radiation therapy. Recurrent disease was treated with salvage SRS with a median dose and fractions of 23.4 Gy (range, 12-30) and 3 (range, 1-3), respectively. Cox proportional hazards regression was conducted to establish predictive factors (P ≤ 0.05) Results: Median follow-up from salvage SRS was 10.8 months (interquartile range [IQR], 7.0-15.6). The median time from initial radiation therapy to salvage SRS was 13.7 months (IQR, 2.9-25.0). The 6- and 12-month overall survival from salvage SRS were 84.9% and 42.5%, respectively. On univariate analysis, STR was associated with inferior survival from salvage SRS (P ≤ 0.05). The 6- and 12-month local control (LC) estimates were 63.1% and 16.4%, respectively. On univariate analysis, higher biological effective dose and prior temozolomide were associated with superior LC. Concerning toxicity, there were 4 (12%) grade 2 and 1 (3%) grade 3 adverse events within this patient series. No grade 4 or grade 5 toxicities were observed. Our outcomes suggest that SRS is a feasible treatment option with acceptable salvage survival rates, given the poor prognosis of this disease.

RTRB-09SALVAGE STEREOTACTIC RADIOSURGERY TO RECURRENT GLIOBLASTOMA MULTIFORME FOLLOWING PRIOR RADIOTHERAPY

BACKGROUND: Due to the poor prognosis of glioblastoma multiforme (GBM) and high recurrence rates, salvage stereotactic radiosurgery (SRS) may be an effective treatment option given its ability to deliver a high dose of radiation within a small volume. Here we investigate the efficacy of salvage SRS for recurrent GBM. METHODS: We retrospectively reviewed 34 patients (41 lesions) treated with salvage SRS for recurrent GBM between 2004-2012. Initial surgical treatments were as follows: gross total resection (58%), subtotal resection (24%), and biopsy (18%). All patients were treated with prior radiotherapy. Recurrent disease was treated with salvage SRS with a median dose of 23.4 Gy (range 12-30) and delivered in a median fraction number of 3 (range 1-3). Cox proportional hazards regression was conducted to establish prognostic factors (p < 0.05). RESULTS: Median follow-up from salvage SRS was 10.8 months (IQR 7.0-15.6). The median time from initial radiotherapy to salvage SRS was 13.7 months (IQR 2.9-25.0). The 6- and 12-month overall survival from salvage SRS were 84.9% and 42.5%, respectively. Upon univariate analysis, subtotal resection (HR = 2.8, p = 0.021) was associated with inferior survival from salvage SRS. The 6- and 12-month local control estimates were 63.1%, and 16.4%, respectively. Using univariate analysis, higher BED (HR = 0.99, p = 0.018) was associated with superior local control. Neither time to recurrence or recurrent tumor volume were associated with local failure. Concerning toxicity, there were 4 (12%) grade 2 and 1 (3%) grade 3 radiation-related toxicities. No grade 4 or 5 toxicities were observed. CONCLUSIONS: Salvage radiosurgery provides an intriguing treatment option for recurrent GBM with minimal toxicity. Our outcomes suggest this is a feasible treatment option with acceptable salvage survival rates given the poor prognosis this diagnosis carries.

Population-based outcomes of boost versus salvage radiosurgery for brain metastases after whole brain radiotherapy

PurposeWe conducted a retrospective population-based study to examine the survival outcomes in patients with brain metastases treated with salvage stereotactic radiosurgery (SRS), compared to boost SRS, after previous whole brain radiotherapy (WBRT). Methods and materialsFrom January 2000 to June 2011, 191 patients treated with WBRT and SRS for brain metastases in British Columbia were studied. Patients were divided into a boost cohort and a salvage cohort. The criteria used to determine eligibility for SRS were: 1–3 metastases, ⩽4cm size, Karnofsky performance status ⩾70, and control of extracranial disease. ResultsDiagnosis by primary site was 84 lung, 47 breast, 15 melanoma, 12 renal, 9 colorectal, and 24 other. There were 113 patients (59%) in the boost cohort and 78 patients (41%) in the salvage cohort. The median overall survival from WBRT for the whole population was 17.7months: 12.1months for the boost cohort and 22.7months for the salvage cohort. There was no difference in median survival after SRS for the boost and salvage cohorts (11.2 vs. 11.2months, p=0.78). ConclusionsIn selected patients with brain metastases treated with WBRT, survival following salvage SRS is as good as survival after WBRT+boost SRS.

Volume specific response criteria for brain metastases following salvage stereotactic radiosurgery and associated predictors of response

Background. We aimed to derive three-dimensional volume-based (V3D) response criteria that approximate those based on Response Evaluation Criteria in Solid Tumours (RECIST) in patients with brain metastases (BM) treated with salvage stereotactic radiosurgery (SRS). Material and methods. Seventy patients with 178 BM were treated with SRS. Each BM was characterised at baseline and at each follow-up MRI according to its widest diameter and V3D using ITK-SNAP image segmentation software. Results. The median tumour diameter was 1.2 cm (range, 0.2–4.5 cm) and V3D was 0.73 cm3 (range, 0.01–22.7 cm3). The V3D percent changes that best matched RECIST response criteria were: an increase of ≥71.5% for progressive disease, a ≥58.5% decrease for partial response and a <58.5% decrease or increase of <71.5% for stable disease (k =0.85). A baseline diameter >3.0 cm (p =0.006) and a V3D >6.0 cm3 (p =0.043) predicted for local failure, and a baseline cumulative V3D of >3.0 cm3 (p =0.02) was adversely prognostic for survival. Conclusions. We define 3D volume specific criteria to base response upon for brain metastases treated with salvage SRS. Tumours with a V3D of greater than 6 cm3 are at a higher risk of local failure.

Salvage stereotactic radiosurgery for breast cancer brain metastases

Salvage stereotactic radiosurgery (SRS) is often considered in breast cancer patients previously treated for brain metastases. The goal of this study was to analyze clinical outcomes and prognostic factors for survival in the salvage setting. The authors retrospectively examined 79 consecutive breast cancer patients who received salvage SRS (interval of >3 months after initial therapy), 76 of whom (96%) received prior whole-brain radiation therapy. Overall survival (OS) and central nervous system (CNS) progression-free survival rates were calculated from the date of SRS using the Kaplan-Meier method. Prognostic factors were evaluated using the Cox proportional hazards model. Median age was 50.5 years. Fifty-eight percent of this population was estrogen receptor positive, 62% was HER2 positive, and 10% was triple negative. At the time of SRS, 95% had extracranial metastases, with 81% of extracranial metastases at other visceral sites (lung/pleura/liver). Forty-eight percent had stable extracranial disease. Median interval from initial brain metastases therapy to SRS was 8.4 months. Median CNS progression-free survival after SRS was 5.7 months (interquartile range [IQR], 3.6-11 months), and median OS was 9.8 months (IQR, 3.8-18 months). Eighty-two percent of evaluable patients received further systemic therapy after SRS. HER2 status (adjusted hazard ratio [HR], 2.4; P = .008) and extracranial disease status (adjusted HR, 2.7; P = .004) were significant prognostic factors for survival on multivariate analysis. In patients with good Karnofsky performance status, salvage SRS for breast cancer brain metastases is a reasonable treatment option, given an associated median survival in excess of 9 months. Furthermore, patients with HER2-positive tumors at diagnosis or stable extracranial disease at the time of SRS have an improved clinical course, with median survival of >1 year.

Salvage stereotactic radiosurgery (SRS) after previous whole-brain radiation therapy (WBRT) for breast cancer brain metastases: Outcomes and prognostic factors including tumor phenotype.

581 Background: Salvage SRS is often considered in breast cancer patients (pts) previously treated with WBRT for brain metastases. The goal of this study was to analyze clinical outcomes and prognostic factors for survival in the salvage setting. Methods: We retrospectively examined all breast cancer pts who underwent SRS at DF/BWCC between 2000 and 2010. We identified 79 consecutive female pts who received salvage SRS (interval of > 3 months after initial therapy), 76 of whom (96%) received prior WBRT. Overall survival (OS) and CNS progression-free survival was calculated from the date of SRS using the Kaplan-Meier method. Prognostic factors were evaluated using the Cox proportional hazards model. Results: Median age was 50.5 years. Subtype distribution was: ER+, 46; HER2+, 27; triple negative, 8). 97% had a KPS ≥70%. 95% had extracranial metastases at the time of SRS, 81% at other visceral sites (lung/pleura/liver). 48% had stable extracranial disease at the time of SRS. Median interval from WBRT to SRS was 8.4 months. Median follow-up for survivors was 16.7 months. Median CNS progression-free survival was 5.7 months (IQR 3.6-11 months) and median OS was 9.8 months (IQR 3.8-18 months). 82% of evaluable pts received further systemic therapy after SRS. 92% of patients were in RPA class II. RPA class was not found to be a useful prognostic index in this population. Median OS in RPA class II pts was 10.4 months. HER2 status (adjusted HR 2.4, p=0.008) and extracranial disease status (adjusted HR 2.7, p=0.004) were significant prognostic factors for survival on multivariate analysis. Conclusions: In patients with good KPS, salvage SRS at the time of CNS recurrence should be strongly considered. HER2 positivity and status of extracranial disease are prognostic factors for survival following SRS in the salvage setting after prior WBRT. Prognostic factors for OS. Univariate Multivariate HR P value HR P value Age >65 y 3.4 0.02 1.8 0.3 Extracranial disease Progessing 2.9 <0.001 2.7 0.004 Stable 1 HER2+ Yes 1 No 2.3 0.002 2.4 0.008 ER+ Yes 0.73 0.2 No 1 Triple-negative Yes 3.8 0.001 1.6 0.3 No 1 KPS <80% 4.2 <0.001 1.9 0.11 N lesions treated SRS 1.1 0.76 Time to SRS 1.0 0.77

Salvage stereotactic radiosurgery effectively treats recurrences from whole‐brain radiation therapy

The purpose of the current study was to examine overall survival (OS) and time to local failure (LF) in patients who received salvage stereotactic radiosurgery (SRS) for recurrent brain metastases (BM) after initial management that included whole-brain radiation therapy (WBRT). The records of 1789 BM patients from August 1989 to November 2004 were reviewed. Of these, 111 underwent WBRT as part of their initial management and SRS as salvage. Patients were stratified by Radiation Therapy Oncology Group (RTOG) recursive partitioning analysis class, primary disease, dimension of the largest metastases and number of BM at initial diagnosis, and time to first brain recurrence after WBRT. Overall survival, survival after SRS, and time to local and distant failure were analyzed. The median OS from the initial diagnosis of BM was 17.7 months. Median survival after salvage SRS for the entire cohort was 9.9 months. Median survival after salvage SRS was 12.3 months in patients who had their first recurrence >6 months after WBRT versus 6.8 months for those who developed disease recurrence < or = 6 months after (P = .0061). Primary tumor site did not appear to affect survival after SRS. Twenty-eight patients (25%) developed local recurrence after their first SRS with a median time of 5.2 months. A dose <22 grays and lesion size >2 cm were found to be predictive of local failure. In this study, patients who recurred after WBRT and were treated with salvage SRS were found to have good local control and survival after SRS. WBRT provided good initial control, as 45% of these patients failed >6 months after WBRT. Those with a longer time to failure after WBRT had significantly longer survival after SRS.