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Background: Immune checkpoint inhibitors (ICIs) are an emerging tool in the treatment of brain metastases (BMs), Stereotactic radiosurgery (SRS), traditionally used for BMs, elicits an immune brain response and can act synergistically with ICIs. We aim to investigate the efficacy of ICI administered with SRS and determine the impact of timing on BM response. Methods: A systematical search was performed to identify potential studies concerning BMs managed with SRS alone or with SRS + ICI with relative timing administration (ICI concurrent with SRS, ICI noncon-current with SRS, SRS before ICI, SRS after ICI). The overall survival (OS), 12-month OS, local progression-free survival (LPFS), 12-month local brain control (LBC), distant progression-free survival (DPFS), 12-month distant brain control (DBC), and adverse events (intracranial hemorrhage, radionecrosis) were analyzed using the random-effects model. Results: A total of 16 retrospective studies with 1356 BM patients were included. Compared to noncon-current therapy, concurrent therapy revealed a significantly longer OS (HR= 1.43; p = 0.008) and 12-months LBC (HR = 1.91; p = 0.04), a similar 12-months DBC (HR = 1.12; p = 0.547) and higher complication rate (R = 0.77; p = 0.346). Concurrent therapy leads to a significantly higher OS compared to ICI before SRS (HR = 2.55; p = 0.0003). Conclusion: The combination of SRS with ICI improves patients' clinical and radiological outcomes. The effectiveness of the combination is subject to the identification of an optimal therapeutic window. [ABSTRACT FROM AUTHOR]

Historically, it is stated that large intracranial tumors, herein defined as a maximum dimension of ≥3 cm or tumor volume ≥14.2 cm3, are not candidates for stereotactic radiosurgery (SRS). We report outcomes of patients with large benign intracranial tumors treated with SRS. With institutional review board approval, we retrospectively identified 74 patients with large benign intracranial tumors (59 meningiomas, 9 vestibular schwannomas, and 6 glomus jugulare tumors) treated with robotic SRS (2007–2018). Patients received definitive SRS in 47.3% of the cases, adjuvant to surgical resection in 44.6%, and salvage after past radiation treatment in 8.1%. A median tumor volume of 16.0 cm3 (range, 10.1–65.5 cm3) received a median dose of 24.0 Gy (range, 14.0–30.0 Gy) in a median of 3 fractions (range, 1–5), for a median single fraction equivalent dose (with alpha/beta of 3) of 14.8 Gy (range, 11.3–18.0 Gy). The Kaplan-Meier estimate of tumor local control (LC) was calculated from date of SRS. With a median clinical follow-up of 32.8 months (range, 0.6–125.9 months) and median radiologic follow-up of 28.5 months (range, 0.6–121.4 months), LC was 96.5% (95% confidence interval, 92.4%–100%) at 3 years and 91.7% (95% confidence interval, 87.6%–95.7%) at 5 years. Adverse radiation effect (ARE) was seen in 10 patients (13.5%) at a median of 13.5 months (range, 7.8–34.5 months). ARE occurred in 9% of those with prior treatment compared with 5% who were radiation-naïve (P = 0.23). With 236.4 person-years of follow-up, no secondary malignancies were seen. Despite the historical adage, we find that SRS provides high rates of LC for these large tumors, with rates of ARE similar to historical reports of SRS for smaller benign tumors. [ABSTRACT FROM AUTHOR]

Gross total resection of large intracranial meningiomas (LIMs) can be challenging and cause significant morbidity and mortality. The aim of this systematic review is to determine the clinical effectiveness and safety of stereotactic radiosurgery (SRS) either as primary or adjuvant therapy for LIMs with tumors ≥2.5 cm in maximum dimension (tumor volume ≥8.1 cm3). A total of 452 tumors in 496 patients (350 female [69.3%] and 146 male [30.6%]) with median age 60 years (48–65 years) were included. The median tumor volume at the time of diagnosis was 16.7 cm3 (10–53.3 cm3). The tumors typically were located in the skull base (77.2%), whereas only 14.6% were in the supratentorial space. The median follow-up after SRS was 54 months (18–90 months). In total, 87.8% of patients were treated with single-session (SS) Gamma Knife radiosurgery (GKS), whereas the remaining 12.1% patients received non-SS GKS. Of 452 LIMs assessed for clinical response, 45.1% showed improvement and 15.7% deteriorated after SRS. Radiographic tumor control at last follow-up (2–7.5 years) ranged from 84% to 100%. Overall, radiation-induced toxicity occurred in 23% of patients, with the most common adverse effect being cranial nerve neuropathy (5.5%) and peritumoral edema (5.3%). Subgroup analysis revealed that there is 2-fold greater likelihood of improvement in clinical symptoms in patients with non-SS GKS than SS GKS (odds ratio 2.47; 95% confidence interval 1.38–4.44; P = 0.002). SRS is safe and effective in the treatment of LIMs as primary or adjuvant treatment. Further prospective studies are required to validate our results. [ABSTRACT FROM AUTHOR]

Background/Objectives: Medulloblastoma is the most common malignant brain tumor in children. In recent decades, the therapeutic landscape has undergone significant changes, with stereotactic radiosurgery (SRS) emerging as a promising treatment for recurrent cases. Our study provides a comprehensive analysis of the long-term efficacy and safety of SRS in recurrent medulloblastomas across both pediatric and adult patients at a single institution. Methods: We retrospectively reviewed the clinical and radiological records of patients who underwent CyberKnife SRS for recurrent cranial medulloblastomas at our institution between 1998 and 2023. Follow-up data were available for 15 medulloblastomas in 10 patients. The cohort comprised eight pediatric patients (ages 3–18) and two adult patients (ages 19–75). The median age at the time of SRS was 13 years, the median tumor volume accounted for 1.9 cc, the median biologically equivalent dose (BED) was 126 Gy, and the single-fraction equivalent dose (SFED) was 18 Gy. The SRS was administered at 75% of the median isodose line. Results: Following a median follow-up of 39 months (range: 6–78), 53.3% of the medulloblastomas progressed, 13.3% regressed, and 33.3% remained stable. The 3-year local tumor control (LTC) rate for all medulloblastomas was 65%, with lower rates observed in the adult cohort (50%) and higher rates in pediatric patients (67%). The 3-year overall survival (OS) rate was 70%, with significantly higher rates in pediatric patients (75%) compared to adult patients (50%). The 3-year progression-free survival (PFS) rate was 58.3%, with higher rates in pediatric patients (60%) compared to adult patients (50%). Two pediatric patients developed radiation-induced edema, while two adult patients experienced radiation necrosis at the latest follow-up, with both adult patients passing away. Conclusions: Our study provides a complex perspective on the efficacy and safety of CyberKnife SRS in treating recurrent cranial medulloblastomas across pediatric and adult populations. The rarity of adverse radiation events (AREs) underscores the safety profile of SRS, reinforcing its role in enhancing treatment outcomes. The intricacies of symptomatic outcomes, intertwined with factors such as age, tumor location, and prior surgeries, emphasize the need for personalized treatment approaches. Our findings underscore the imperative for ongoing research and the development of more refined treatment strategies for recurrent medulloblastomas. Given the observed disparities in treatment outcomes, a more meticulous tailoring of treatment approaches becomes crucial. [ABSTRACT FROM AUTHOR]

Trigeminal neuralgia (TN) is a paroxysmal, unilateral, brief, shock-like pain in ≥1 divisions of the trigeminal nerve. It can result from multiple causes; however, TN secondary to stroke is very rare. We present the case of TN secondary to pontine infarction treated with incremental doses of neuropathic pain medication for >5 years before conservative management failed. He was then treated with stereotactic radiosurgery (SRS). Additionally, we conducted a systematic review using standard PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines for all the cases of TN with brainstem stroke from 1976 to 2022. Our patient was an 82-year-old man. Magnetic resonance imaging demonstrated a pontine lesion consistent with stroke. The Barrow Neurological Institute (BNI) score at presentation was 5. He received a marginal dose of 60 Gy to the 80% isodose line in a single fraction to a volume of 0.05 cm3. The immediate post-treatment BNI score was 0 and remained at 0 for 3 months, when he experienced recurrence. The recurrence was treated with oxcarbazepine. His pain remained well controlled with a lower dose of oxcarbazepine, and he had no adverse effects at 1 year of follow-up with a BNI score of 3. The systemic review identified 21 case reports with a combined cohort of 25 patients with TN secondary to stroke. Only 3 patients were treated with SRS, 2 of whom reported symptom improvement at 6 months and 8 months of follow-up with no adverse events. Our case and literature review demonstrate durable and effective treatment with SRS, which can be considered a safe and effective treatment option for patients with stroke-associated TN. [ABSTRACT FROM AUTHOR]

Choroid plexus papillomas (CPPs) are rare intraventricular brain tumors derived from the epithelium of the choroid plexus. Gross total resection has traditionally been considered curative, but residual tumor or recurrence remains possible. Stereotactic radiosurgery (SRS) has become a more important strategy for subtotally resected and recurrent tumors. The evidence-based rationale of SRS treatment for residual or recurrent CPP in adult patients is still lacking because of the rarity of the disease. We retrospectively reviewed the cases of histopathologically confirmed patients with residual or recurrent CPP treated with SRS at our institute in the adult population between 2005 and 2022. Three patients, with 5 lesions, were identified, with a median age of 63 years. Patients presented initially with hydrocephalus-related symptoms, although ventriculomegaly was noted in only 1 patient radiographically. The tumor location was most commonly in the fourth ventricle or along the foramen of Luschka. Treatment was delivered in a single fraction in 4 lesions and in 3 fractions in 1 patient. The median follow-up was 26 months. The local tumor control rate for the lesions was 80%. One patient developed a new lesion outside the SRS field, and 1 lesion developed progression without the need for subsequent treatment. There was no significant shrinkage of the lesions radiographically. None of the patients showed radiation-related adverse events. No patients required surgical management after SRS treatment at our institution. Based on the literature review, our case series was the second largest retrospective series from a single institution on SRS for recurrent or residual CPP. SRS for patients with recurrent or residual CPP was a safe and effective treatment modality in this case series. Larger studies are encouraged to validate the role of SRS in the treatment of recurrent or residual CPP. [ABSTRACT FROM AUTHOR]

Stereotactic radiosurgery (SRS) is a well-established treatment for vestibular schwannomas (VS). Hearing loss remains a main morbidity of VS and its treatments, including SRS. The effects of radiation parameters of SRS on hearing remain unknown. The goal of this study is to determine the effect of tumor volume, patient demographics, pretreatment hearing status, cochlear radiation dose, total tumor radiation dose, fractionation, and other radiotherapy parameters on hearing deterioration. Multicenter retrospective analysis of 611 patients who underwent SRS for VS from 1990–2020 and had pre- and post-treatment audiograms. Pure tone averages (PTAs) increased and word recognition scores (WRSs) decreased in treated ears at 12–60 months while remaining stable in untreated ears. Higher baseline PTA, higher tumor radiation dose, higher maximum cochlear dose, and usage of single fraction resulted in higher post radiation PTA; WRS was only predicted by baseline WRS and age. Higher baseline PTA, single fraction treatment, higher tumor radiation dose, and higher maximum cochlear dose resulted in a faster deterioration in PTA. Below a maximum cochlear dose of 3 Gy, there were no statistically significant changes in PTA or WRS. Decline of hearing at one year in VS patients after SRS is directly related to maximum cochlear dose, single versus 3-fraction treatment, total tumor radiation dose, and baseline hearing level. The maximum safe cochlear dose for hearingtbrowd preservation at one year is 3 Gy, and the use of 3 fractions instead of one fraction was better at preserving hearing. [ABSTRACT FROM AUTHOR]

Langerhans cell histiocytosis (LCH) is a rare idiopathic disease characterized by the clonal proliferation of Langerhans histiocytes in various parts of the body and capable of leading to organ damage and tumor formation. Reports of cranial LCH in the adult population are extremely rare. Although surgery remains the preferred option for localized LCH lesions, the role of stereotactic radiosurgery (SRS) is emerging. To retrospectively review a rare case series to determine the safety and effectiveness of SRS for patients with localized cranial LCH. We retrospectively reviewed histopathologically confirmed cases of localized cranial LCH treated with SRS at our institute in the adult population between January 2005 and September 2022. Five patients were identified with a median age of 34 years (19–54 years). The tumor location was in the pituitary stalk in 3 patients, the orbit in one patient, and the parietal skull in one patient. The median target volume was 2.8 cc (range: 0.37–6.11). Treatment was delivered in a single fraction in 4 patients (median margin dose of 8 Gy, range: 7–10 Gy) and in 3 fractions (22.5 Gy) in 1 patient. The median follow-up was 12 years (range: 4–17). None of the patients required craniotomy for tumor debulking before or after SRS. The local tumor control rate for the lesions was 100%. All 3 patients with LCH in the pituitary stalk had diabetes insipidus at the initial presentation and developed panhypopituitarism after SRS. Diabetes insipidus was not improved after SRS. The other 2 patients presented no adverse radiation effects. Based on the literature review, our case series was the largest retrospective series on SRS for localized cranial LCH, with the longest median follow-up. SRS for patients with localized cranial LCH was a safe and effective treatment modality in this case series. Larger studies are encouraged to validate the role of SRS in the treatment of localized cranial LCH. [ABSTRACT FROM AUTHOR]

Background: Stereotactic radiosurgery (SRS) is the standard of care for patients with a limited number of brain metastases. Despite the fact that the seminal studies regarding SRS for brain metastases were largely tissue agnostic, several current national guidelines do not uniformly recommend SRS in thyroid cancer. We therefore investigated oncological outcomes in a cohort of patients with brain metastases from thyroid cancer who received radiotherapy (RT) at our institution as well as those in a nationally representative cancer cohort, the National Cancer Database (NCDB). Materials and Methods: We identified patients with thyroid cancer and brain metastases treated with RT at our institution from 2002 through 2020. For the NCDB cohort, the national database of patients with thyroid cancer was screened on the basis of brain-directed RT or brain metastases. For the institutional cohort, the cumulative risk of local failure (LF), distant intracranial failure, and radiation necrosis were calculated, adjusted for the competing risk of death. Overall survival (OS) in both cohorts was analyzed using the Kaplan–Meier method. Univariate analysis was accomplished via clustered competing risks regression. Results: For the institutional cohort, we identified 33 patients with 212 treated brain metastases. OS was 6.6 months. The 1-year cumulative incidences of LF and distant intracranial failures were 7.0% and 38%, respectively. The 1-year risk of radiation necrosis was 3.3%. In the NCDB cohort, there were 289 patients, and the median survival was 10.2 months. NCDB national practice patterns analysis showed an increasing use of SRS over time in both the entire cohort and the subset of anaplastic patients. Univariate analysis was performed for OS, risk of LF, risk of regional intracranial failure, and risk of radiation necrosis. Conclusions: SRS is a safe, effective, and increasingly utilized treatment for thyroid cancer brain metastases of any histology and should be the standard of care treatment. [ABSTRACT FROM AUTHOR]

Head and neck paragangliomas (HNPs) are rare, usually benign hyper vascularized neuroendocrine tumors that traditionally have been treated by surgery, with or without endovascular embolization, or, more recently stereotactic radiosurgery (SRS). The aim of our study is to determine the clinical and radiographic effectiveness of SRS for treatment of HNPs. A systematic search of electronic databases was performed, and 37 articles reporting 11,174 patients (1144 tumors) with glomus jugulare (GJT: 993, 86.9%), glomus tympanicum (GTT: 94, 8.2%), carotid body tumors (CBTs: 28, 2.4%), and glomus vagale (GVT: 16, 1.4%) treated with SRS definitively or adjuvantly were included. The local control (LC) was estimated from the pooled analysis of the series, and its association with SRS technique as well as demographic and clinical factors was analyzed. The median age was 56 years (44–69 years). With a median clinical and radiological follow-up of 44 months (9–161 months), LC was 94.2%. Majority of the patients (61.0%) underwent Gamma Knife Radiosurgery (GKS), but there was no statistically significant difference in LC depending upon the SRS technique (p = 0.9). Spearmen's correlation showed that LC was strongly and negatively correlated with multiple parameters, which included female gender (r = − 0.4, p = 0.001), right-sided tumor (r = − 0.3, p = 0.03), primary SRS (r = − 0.5, p ≤ 0.001), and initial clinical presentation of hearing loss (r = − 0.4, p = 0.001). To achieve a LC ≥ 90%, a median marginal dose (Gy) of 15 (range, 12–30 Gy) was required. The results corroborate that SRS in HNPs is associated with good clinical and radiological outcome. [ABSTRACT FROM AUTHOR]

To determine the efficacy of stereotactic radiosurgery (SRS) in treating patients with brain metastases (BMs), a network meta-analysis (NMA) of randomized controlled trials (RCTs) and a direct comparison of cohort studies were performed. Relevant literature regarding the effectiveness of SRS alone and in combination with whole-brain radiotherapy (WBRT) and surgery was retrieved using systematic database searches up to April 2019. The patterns of overall survival (OS), one-year OS, progression-free survival (PFS), one-year local brain control (LBC), one-year distant brain control (DBC), neurological death (ND), and complication rate were analyzed. A total of 18 RCTs and 37 cohorts were included in the meta-analysis. Our data revealed that SRS carried a better OS than SRS+WBRT (p = 0.048) and WBRT (p = 0.041). Also, SRS+WBRT demonstrated a significantly improved PFS, LBC, and DBC compared to WBRT alone and SRS alone. Finally, SRS achieved the same LBC as high as surgery, but intracranial relapse occurred considerably more frequently in the absence of WBRT. However, there were not any significant differences in ND and toxicities between SRS and other groups. Therefore, SRS alone may be a better alternative since increased patient survival may outweigh the increased risk of brain tumor recurrence associated with it. [Display omitted] • WBRT+SRS is better than SRS alone in terms of LBC and DBC. • WBRT+SRS carries a prolonged survival with higher LBC, DBC when compared to WBRT. • LBC is high in either surgery or SRS, but it is significantly higher in SRS. • Surgery+SRS achieved higher LBC than surgery+WBRT, but resulted in worse regional control. • SRS+WBRT had longer PFS when compared to SRS alone and WBRT. [ABSTRACT FROM AUTHOR]