Neoadjuvant Stereotactic Radiosurgery: a Further Evolution in the Management of Brain Metastases

Recent randomized evidence has supported the use of resection followed by stereotactic radiosurgery (SRS) as standard of care for patients with a limited number of brain metastases. However, there are known toxicities, including a relatively high incidence of leptomeningeal disease. Neoadjuvant SRS has been proposed to minimize these potential sequalae. This review summarizes the current data and principles for neoadjuvant SRS.

Recently published studies have demonstrated neoadjuvant SRS to be feasible and to achieve similar oncological outcomes to postoperative SRS. A decreased incidence of leptomeningeal disease and radionecrosis has been observed. Additionally, neoadjuvant SRS can improve accuracy of target volume delineation and decrease the volume of irradiated normal tissue. Neoadjuvant SRS has emerged as a promising sequencing management approach. Its main advantages appear to be in reduction of toxicity. Ongoing trials will further explore this treatment method and establish which patients will benefit most from this technique.