Management of recurrent brain metastasis after radiosurgery

Stereotactic radiosurgery (SRS) has become a first-line treatment option for brain metastases, both as a boost following whole-brain radiation therapy (WBRT), and as stand-alone treatment. When SRS is used as a single modality treatment, the local and distant brain recurrence rates range from 73 to 76.4%. When used in combination with WBRT, recurrence rates range from 27 to 46.8%. As systemic therapies improve, the number of patients who develop new or recurrent brain metastases after SRS is likely to increase. The evidence regarding the safety and efficacy of salvage therapies is very limited, making options for treatment unclear and controversial. In this report, we review current diagnostic challenges regarding local recurrence after SRS and the development of new brain metastases after SRS. Potential therapeutic strategies and the patients for who each is recommended are discussed, including repeat SRS, surgical resection, WBRT, fractionated stereotactic radiosurgery, chemotherapy, and supportive care.