| Coverage Policy Manual | |
| Policy #: | 1997210 |
| Category: | Surgery |
| Initiated: | July 1994 |
| Last Review: | March 2024 |
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| Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy Gamma Knife Surgery, Linear Accelerator, Cyberknife, TomoTherapy | |
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| Description: |
Stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT) are techniques that use highly focused, conformal radiation beams to treat both neoplastic and non-neoplastic conditions. SRS and SBRT rely on 3-dimensional imaging to localize the therapy target. Because they are more targeted than traditional external radiation therapy, SRS and SRBT are often used for treatment at sites that are difficult to reach via surgery, located close to other vital structures, or subject to movement within the body. SRS primarily refers to such radiotherapy applied to intracranial lesions. SBRT refers to therapy generally applied to other areas of the body. Both techniques differ from conventional external-beam radiotherapy, which involves exposing large areas of tissue to relatively broad fields of radiation over multiple sessions.
Although SRS and SBRT may be completed with 1 session (single-fraction), additional sessions (typically no more than 5) over a course of days, referred to as fractionated stereotactic radiotherapy, may be required.
SRS and SBRT can be administered by several types of devices that are distinguished by their source of radiation, including particle beams (proton), gamma rays from cobalt-60 sources, or high-energy photons from linear accelerator (LINAC) systems. The use of charged particle (proton beam) radiation therapies is addressed in a separate policy (Policy No. 2008012). The most commonly used gamma ray device is the Gamma Knife® (Elekta, Inc., Stockholm), which is a fixed device used for intracranial lesions, typically for smaller lesions. Several brands of LINAC devices are available, including the Novalis Tx® (Novalis, Westchester, IL), the TrueBeamSTx (Varian Medical Systems, Palo Alto, CA), and the CyberKnife® system (Accuray, Sunnyvale, CA).
Non-Neoplastic Conditions Treated with SRS
Arteriovenous malformations consist of a tangled network of vessels in which blood passes from arteries to veins without intervening capillaries. They range in size from small, barely detectable lesions to huge lesions that can occupy an entire hemisphere. SRS incites an inflammatory response in the vessels, which results in ongoing fibrosis with eventual complete obliteration of the lesion over a course of months to years. This latency period is variable, depending on the size of the AVM and the dose distribution of the radiosurgery. During this latency period, there is an ongoing but declining risk of hemorrhage. In contrast, surgical excision provides an immediate effect on the risk of hemorrhage. Total surgical extirpation of the lesion, if possible, is the desired form of therapy to avoid future hemorrhage. However, a small subset of AVMs because of their size or location cannot be excised without serious neurologic sequelae. SRS is an important alternative in these patients.
Trigeminal neuralgia is a disorder of the fifth cranial (i.e. trigeminal) nerve that causes episodes of intense, stabbing pain in the face. Although trigeminal neuralgia is initially treated medically, in a substantial number of cases, drug treatment is either ineffective or the adverse effects become intolerable. Neurosurgical options include microvascular decompression, balloon compression, and rhizotomy. SRS has been investigated as an alternative to these neurosurgical treatments.
Seizure disorders are initially treated medically. Surgical treatment is only considered in those rare instances when the seizures have proven refractory to all attempts at aggressive medical management, when the seizures are so frequent and severe as to significantly diminish quality of life, and when the seizure focus can be localized to a focal lesion in a region of the brain that is amenable to resection. SRS has been investigated as an alternative to neurosurgical resection.
For chronic pain that is refractory to a variety of medical and psychological treatments, there are a variety of surgical alternatives.Neuro-destructive procedures include cordotomy, myelotomy, dorsal root entry zone (DREZ) lesions, and stereotactic radiofrequency thalamotomy. SRS targeting the thalamus has been considered an investigative alternative to these neuro-destructive procedures.
SRS for the destruction of the thalamic nuclei (thalamotomy) has been proposed for a treatment of essential tremor and other forms of tremor (ie, secondary to Parkinson’s disease, multiple sclerosis, or other neurologic conditions), as an alternative to medical therapy or surgical therapy in extreme cases.
Benign Neoplastic Intracranial Lesions Treated with SRS
SRS is used for primary intracranial tumors and tumors that are relatively inaccessible surgically and that are often near eloquent or radiosensitive areas such as symptomatic acoustic neuroma, pituitary adenoma, craniopharyngioma, and glomus jugulare tumor.
Acoustic neuromas, also called vestibular schwannomas, are benign tumors originating on the eighth cranial nerve, sometimes seen in association with neurofibromatosis, which can be associated with significant morbidity and even death if their growth compresses vital structures. The tumors arise from the Schwann cell sheath surrounding the vestibular or cochlear branches of the eighth cranial nerve. Pituitary adenomas are benign tumors with symptoms related to hormone production (ie, functioning adenomas) or neurologic symptoms due to tumor impingement on surrounding neural structures. Craniopharyngiomas are benign tumors that arise from pituitary embryonic tissue at the base of the gland. However, because of their proximity to the optic pathways, pituitary gland, and hypothalamus, these tumors may cause severe and permanent damage to these critical structures and can be life-threatening. A glomus jugulare tumor is a rare, benign tumor arising in the skull temporal bone that involves middle and inner ear structures.
For acoustic neuromas, radiosurgery has been used as a primary treatment or as a treatment for recurrence after incomplete surgical resection. For pituitary adenomas, SRS has been used as a primary treatment. For pituitary adenomas, surgical excision is typically offered to patients with functioning adenomas because complete removal of the adenoma leads to more rapid control of autonomous hormone production. In patients with nonfunctioning adenomas, the treatment goal is to control growth; complete removal of the adenoma is not necessary. Conventional radiotherapy has been for nonfunctioning adenomas with an approximate 90% success rate and few complications. For craniopharyngiomas, total surgical resection is often difficult. For glomus jugulare tumors, no consensus exists on optimal management to control tumor burden while minimizing treatment-related morbidity.
Malignant Neoplastic Intracranial Lesions Treated with SRS
SRS is used to treat certain primary and metastatic intracranial malignant tumors including gliomas, malignant meningiomas, and primitive neuroectodermal tumors (ie, medulloblastoma, pineoblastoma) that are relatively inaccessible surgically and which are often located in proximity to eloquent or radiosensitive areas. Treatment of primary brain tumors such as gliomas is more challenging, due to their generally larger size and infiltrative borders. Intracranial metastases tend to have a smaller spherical size and noninfiltrative borders. Brain metastases occur frequently, seen in 25% to 30% of all patients with cancer, particularly in those with cancer of the lung, breast, colon , melanoma, and kidney. SRS is typically used as an alternative to open neurosurgical intervention. SRS offers the additional ability to treat tumors with relative sparing of normal brain tissue in a single-fraction.
Uveal Melanoma Treated with SRS
Melanoma of the uvea (choroid, ciliary body, and iris) is the most common, primary, malignant, intraocular tumor in adults. The following therapies are established treatment modalities for the treatment of uveal melanoma: enucleation, local resection, brachytherapy, and proton beam radiotherapy. Photodynamic therapy with verteporfin has also been used as a primary treatment for choroidal melanoma. The main objectives of treating the tumor are 2-fold: (1) to reduce the risk of metastatic spread; and (2) to salvage the eye with useful vision (if feasible). Treatment selection depends on tumor size and location, associated ocular findings, the status of the other eye, as well as other individual factors, including age, life expectancy, QOL, concurrent systemic diseases, and patient expectations. SRS may be used as an alternative to enucleation of the eye.
Stereotactic Body Radiotherapy
The purpose of SBRT is to use a focused radiotherapy technique to treat certain primary and metastatic extracranial tumors that are relatively inaccessible surgically and that are often located in proximity to radiosensitive organs at risk. SBRT has resulted in improved overall survival, symptoms, and treatment-related morbidity for individuals with the following conditions: stage T1 or T2A non-small cell lung cancer who are not candidates for surgical resection; primary or metastatic tumor of the liver that is considered inoperable; primary prostate carcinoma; pancreatic adenocarcinoma; primary or metastatic renal cell carcinoma who are not good surgical candidates; oligometastases involving lung, adrenal glands, or bone (other than spine or vertebral body; and primary and metastatic spinal or vertebral body tumors who have received prior spinal radiotherapy).
Regulatory Status
Several devices that use cobalt 60 radiation (gamma-ray devices) for SRS have been cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process. The most commonly used gamma-ray device, approved in 1999, is the Gamma Knife® (Elekta; product code IWB), which is a fixed device used only for intracranial lesions. Gamma-ray emitting devices that use cobalt 60 degradation are also regulated through the U.S. Nuclear Regulatory Commission.
A number of LINAC movable platforms that generate high-energy photons have been cleared for marketing by the FDA through the 510(k) process. Examples include the Novalis Tx® (Novalis); the TrueBeam STx (Varian Medical Systems; approved 2012; FDA product code IYE); and the CyberKnife® Robotic Radiosurgery System (Accuray; approved 1998; FDA product code MUJ). LINAC-based devices may be used for intracranial and extracranial lesions.
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Policy/ Coverage: |
Effective August 1, 2021, for members of plans that utilize a radiation oncology benefits management program, Prior Approval is required for this service and is managed through the radiation oncology benefits management program.
Effective April 14, 2024
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
Stereotactic Radiosurgery (SRS)
Stereotactic radiosurgery (SRS) using a gamma or LINAC unit meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for the following indications:
Intracranial Lesions
Malignant Brain Lesions
Benign Brain Lesions
Ocular Lesions
Neurologic Indications
Trigeminal Neuralgia
Mesial temporal lobe epilepsy
Sarcoma, Thymoma and Thymic Carcinoma
Stereotactic Body Radiotherapy (SBRT)
Stereotactic body radiotherapy (SBRT) meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for the following indications:
Spinal Lesions: Primary Or Metastatic Lesions Of The Spine
Spine Lesions
Colorectal and Anal Cancers
Cholangiocarcinoma, Esophageal, Gastric Cancers
Liver Cancer
Hepatocellular Carcinoma
Liver Metastasis
Pancreatic Cancer
Genitourinary Cancer (Bladder, Penile, and Testicular)
Gynecologic Cancers: (Cervical, Fallopian Tube, Ovarian, Uterine, and Vulvar/Vaginal)
Head and Neck or Thyroid Cancer
Lung Cancer
Small Cell and Non-Small Cell Lung Cancers
Metastatic Lesions in the Lung
Prostate cancer
Extracranial Oligometastases
Other Malignancies
⦁ Only for retreatment of a previously irradiated field.
Stereotactic Radiosurgery (SRS) or Stereotactic Body Radiotherapy (SBRT)
Stereotactic radiosurgery (SRS) using a gamma or LINAC or Stereotactic body radiotherapy (SBRT) meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for the following indications:
Brain
Breast Cancer
Bone Metastases
Hodgkin and Non-Hodgkin Lymphoma
Pediatric (age 20 years or younger) Tumors
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
Stereotactic radiosurgery or stereotactic body radiation therapy for the treatment of functional disorders other than trigeminal neuralgia, including epilepsy and chronic pain, or for any other condition not listed above as covered does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness and is not covered.
For members with contracts without primary coverage criteria, stereotactic radiosurgery or stereotactic body radiation therapy for the treatment of functional disorders other than trigeminal neuralgia, including epilepsy and chronic pain, or for any other condition not listed above as covered, is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
Effective August 2023 to April 13, 2024
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
Stereotactic Radiosurgery (SRS)
Stereotactic radiosurgery (SRS) using a gamma or LINAC unit meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for the following indications:
Intracranial Lesions
Malignant Brain Lesions
Benign Brain Lesions
Ocular Lesions
Neurologic Indications
Trigeminal Neuralgia
Mesial temporal lobe epilepsy
Sarcoma, Thymoma and Thymic Carcinoma
Stereotactic Body Radiotherapy (SBRT)
Stereotactic body radiotherapy (SBRT) meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for the following indications:
Spinal Lesions: Primary Or Metastatic Lesions Of The Spine
Spine Lesions
COLORECTAL AND ANAL CANCERS
CHOLANGIOCARCINOMA, ESOPHAGEAL, GASTRIC CANCERS
Liver Cancer
Hepatocellular Carcinoma
Liver Metastasis
Pancreatic Cancer
Genitourinary Cancer (Bladder, Penile, and Testicular)
Gynecologic Cancers: (Cervical, Fallopian Tube, Ovarian, Uterine, and Vulvar/Vaginal)
Head and Neck or Thyroid Cancer
Lung Cancer
Small Cell and Non-Small Cell Lung Cancers
Metastatic Lesions in the Lung
Prostate cancer
Extracranial Oligometastases
Other Malignancies
⦁ Only for retreatment of a previously irradiated field.
Stereotactic Radiosurgery (SRS) or Stereotactic Body Radiotherapy (SBRT)
Stereotactic radiosurgery (SRS) using a gamma or LINAC or Stereotactic body radiotherapy (SBRT) meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for the following indications:
Brain
Breast Cancer
Bone Metastases
Hodgkin and Non-Hodgkin Lymphoma
Pediatric (age 20 years or younger) Tumors
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
Stereotactic radiosurgery or stereotactic body radiation therapy for the treatment of functional disorders other than trigeminal neuralgia, including epilepsy and chronic pain, or for any other condition not listed above as covered does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness and is not covered.
For members with contracts without primary coverage criteria, stereotactic radiosurgery or stereotactic body radiation therapy for the treatment of functional disorders other than trigeminal neuralgia, including epilepsy and chronic pain, or for any other condition not listed above as covered, is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
Effective April 09, 2023 through July 2023
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
Stereotactic Radiosurgery (SRS)
Stereotactic radiosurgery (SRS) using a gamma or LINAC unit meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for the following indications:
Stereotactic Body Radiotherapy (SBRT)
Stereotactic body radiotherapy (SBRT) meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for the following indications:
Stereotactic Radiosurgery (SRS) or Stereotactic Body Radiotherapy (SBRT)
Stereotactic radiosurgery (SRS) using a gamma or LINAC or Stereotactic body radiotherapy (SBRT) meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for the following indications:
Brain
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
Stereotactic radiosurgery or stereotactic body radiation therapy for the treatment of functional disorders other than trigeminal neuralgia, including epilepsy and chronic pain, or for any other condition not listed above as covered does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness and is not covered.
For members with contracts without primary coverage criteria, stereotactic radiosurgery or stereotactic body radiation therapy for the treatment of functional disorders other than trigeminal neuralgia, including epilepsy and chronic pain, or for any other condition not listed above as covered, is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
Effective November 2022 to April 09, 2023
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
Stereotactic Radiosurgery (SRS)
Stereotactic radiosurgery (SRS) using a gamma or LINAC unit meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for the following indications:
Stereotactic Body Radiotherapy (SBRT)
Stereotactic body radiotherapy (SBRT) meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for the following indications:
Stereotactic Radiosurgery (SRS) or Stereotactic Body Radiotherapy (SBRT)
Stereotactic radiosurgery (SRS) using a gamma or LINAC or Stereotactic body radiotherapy (SBRT) meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for the following indications:
Stereotactic radiosurgery or stereotactic body radiotherapy performed using fractionation for the indications outlined above meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness. (Fractionated SRS refers to SRS or SBRT performed more than once on a specific site. SRS is most often single-fraction treatment; however, multiple fractions may be necessary when lesions are near critical structures. SBRT is commonly delivered over 3 to 5 fractions.)
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
Stereotactic radiosurgery for any condition or application not listed above does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
For members with contracts without primary coverage criteria, stereotactic radiosurgery for any condition or application not listed above is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
Stereotactic body radiotherapy for any condition or application not listed above does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
For members with contracts without primary coverage criteria, stereotactic body radiotherapy for any condition or application not listed above is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
Effective May 2022 to October 2022
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
Stereotactic Radiosurgery (SRS)
Stereotactic radiosurgery (SRS) using a gamma or LINAC unit meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for the following indications:
Stereotactic Body Radiotherapy (SBRT)
Stereotactic body radiotherapy (SBRT) meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for the following indications:
Stereotactic Radiosurgery (SRS) or Stereotactic Body Radiotherapy (SBRT)
Stereotactic radiosurgery (SRS) using a gamma or LINAC or Stereotactic body radiotherapy (SBRT) meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for the following indications:
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
Stereotactic radiosurgery or stereotactic body radiation therapy for the treatment of functional disorders other than trigeminal neuralgia, including epilepsy and chronic pain, or for any other condition not listed above as covered does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness and is not covered.
For members with contracts without primary coverage criteria, stereotactic radiosurgery or stereotactic body radiation therapy for the treatment of functional disorders other than trigeminal neuralgia, including epilepsy and chronic pain, or for any other condition not listed above as covered, is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
Effective February 15, 2022 to April 2022
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
Stereotactic Radiosurgery (SRS)
Stereotactic radiosurgery (SRS) using a gamma or LINAC unit meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for the following indications:
Stereotactic Body Radiotherapy (SBRT)
Stereotactic body radiotherapy (SBRT) meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for the following indications:
Stereotactic Radiosurgery (SRS) or Stereotactic Body Radiotherapy (SBRT)
Stereotactic radiosurgery (SRS) using a gamma or LINAC or Stereotactic body radiotherapy (SBRT) meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for the following indications:
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
Stereotactic radiosurgery or stereotactic body radiation therapy for the treatment of functional disorders other than trigeminal neuralgia, including epilepsy and chronic pain, or for any other condition not listed above as covered does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness and is not covered.
For members with contracts without primary coverage criteria, stereotactic radiosurgery or stereotactic body radiation therapy for the treatment of functional disorders other than trigeminal neuralgia, including epilepsy and chronic pain, or for any other condition not listed above as covered, is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
Effective September 2021 to February 15, 2022
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
Stereotactic Radiosurgery (SRS)
Stereotactic radiosurgery (SRS) using a gamma or LINAC unit meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for the following indications:
Stereotactic Body Radiotherapy (SBRT)
Stereotactic body radiotherapy (SBRT) meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for the following indications:
Stereotactic Radiosurgery (SRS) or Stereotactic Body Radiotherapy (SBRT)
Stereotactic radiosurgery (SRS) using a gamma or LINAC or Stereotactic body radiotherapy (SBRT) meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for the following indications:
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
Stereotactic radiosurgery or stereotactic body radiation therapy for the treatment of functional disorders other than trigeminal neuralgia, including epilepsy and chronic pain, or for any other condition not listed above as covered does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness and is not covered.
For members with contracts without primary coverage criteria, stereotactic radiosurgery or stereotactic body radiation therapy for the treatment of functional disorders other than trigeminal neuralgia, including epilepsy and chronic pain, or for any other condition not listed above as covered, is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
Due to the detail of the policy statement, the document containing the coverage statements for dates prior to August 2021 are not online. If you would like a hardcopy print, please email: codespecificinquiry@arkbluecross.com
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| Rationale: |
Due to the detail of the rationale, the complete document is not online. If you would like a
hardcopy print, please email: specificinquiry@arkbluecross.com
2015 Update
A literature search conducted through December 2014 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
Data on the use of SRS and SBRT consists primarily of case series, registry data and early phase trials, with a limited number of randomized controlled trials (RCTs) and nonrandomized comparative trials.
The selection of variables used in the delivery of SRS and SBRT is complex and individualized, requiring selection of the device, radiation dose, and the size and shape of treatment margins, all of which depend on the location, shape, and radiosensitivity of the target tissue and the function and radiosensitivity of the surrounding tissue. Several ongoing questions exist in the evaluation of SRS and SBRT, related to most appropriate choices of:
Trials that would allow direct comparison of all of the possible variables involved in selecting specific SRS and SBRT methods do not currently exist. Therefore, the available evidence is inadequate to permit scientific conclusions about specific radiation planning and delivery techniques, including the specific number of fractions and methods of dose escalation or toxicity reduction. Therefore, the following discussion groups together several different techniques for delivering SRS and SBRT and does not attempt to compare specific radiation planning and delivery techniques.
Stereotactic Radiosurgery
Non-Neoplastic Conditions
Arteriovenous Malformations
In 2014, Mohr et al reported results of the ARUBA trial, a randomized, multicenter trial to compare medical therapy to medical therapy with interventional therapy (including any neurosurgical, endovascular, or stereotactic radiotherapy procedure) in patients with unruptured arteriovenous malformations (AVM) (Mohr, 2014). Two hundred and twenty-six patients were enrolled and randomized, 116 to interventional therapy and 110 to medical management. Among those randomized to interventional therapy, 91 received interventional therapy, 5 with neurosurgery alone, 30 with embolization alone, 31 with radiotherapy alone, 12 with embolization and neurosurgery, 15 with embolization and radiotherapy, and 1 with all three. The trial was stopped early by its data and safety monitoring board after interim analysis demonstrated superiority of medical management, after outcomes were available for 223 patients with mean follow up time of 33.3 months. The risk of death or stroke was lower in the medical management group than in the interventional therapy group (hazard ratio [HR] 0.27, 95% CI 0.14 to 0.54). Patients will continue to be followed to determine whether differences in outcomes persist. Although a high proportion of patients randomized to interventional therapy (40.5%) received at least some radiotherapy, outcomes are not reported by therapy type, making it difficult to assess the comparative effectiveness of SRS in AVM treatment.
Paul et al conducted a retrospective cohort study that included 697 SRS treatments in 662 patients treated with SRS for brain AVMs at a single institution (Paul, 2014). The obliteration rate after a single or multiple SRS procedures was 69.3% and 75%, respectively. The obliteration rates were significantly associated with AVMs that were compact (odds ratio [OR] 3.16, 95% CI 1.92 to 5.22), with undilated feeders (OR 0.36, 95% CI 0.23 to 0.57), with smaller volume (OR 0.95, 95% CI 0.92 to 0.99) and that were treated with higher marginal dose (OR 1.16, 95% CI 1.06 to 1.27).
Bowden et al reported outcomes from a retrospective cohort study of patients with cerebellar AVM treated with SRS at a single institution (Bowden, 2014). Sixty-four patients were included, 73% of whom had presented with intracranial hemorrhage and 19% of whom had undergone prior embolization. Total obliteration was achieved at 3, 4, and 5-10 years in 52%, 69%, and 75%, respectively, of subjects. Obliteration was more likely in smaller AVMs but less likely in patients who had undergone prior embolization. Symptomatic adverse radiation events, defined by MRI changes and new neurologic deficits in the absence of hemorrhage, occurred in 3 patients.
Fokas et al reported long-term follow up of a cohort of patients who underwent SRS for cerebral AVMs at a single institution (Fokas, 2014). One hundred sixty-four patients were identified, with a median follow up of 93 months (range 12-140 months). Thirty-nine percent of subjects had experienced a prior intracranial hemorrhage, and 43.3% and 8.0%, respectively, had undergone prior embolization or neurosurgical procedures. Complete obliteration was seen in 61% of patients at a median time of 29 months. Complete obliteration was achieved at 3 and 5 years in 61% and 88%, respectively. In multivariable models, higher radiation dosage and smaller target volumes were associated with higher rates of complete obliteration. The annual bleeding risk was 1.3% per year during follow up.
Matsuo et al reported outcomes from a cohort of 51 patients with intracranial AVMs treated with SRS at a single institution (Matsuo. 2014). Rates of obliteration after a single SRS at 3, 5, 10, and 15 years were 46.9%, 54.%, 64,%, and 68%, respectively; rates of obliteration after multiple SRS sessions at 3, 5, 10, and 15 years were 46.9%, 61.3%, 74.2%, and 90.3%, respectively. The adverse radiation events occurred in 9 cases (17.6%), with 4 cases (3 symptomatic cysts and 1 intracranial hemorrhage) not occurring until 10 years after the SRS treatment.
Potts et al summarized outcomes for 80 children treated with SRS for intracranial AVMs, most of whom (56%) had intracranial hemorrhage at the time of presentation (Potts, 2014). Among the 47% of subjects with available angiograms 3 years after treatment, AVM obliteration occurred in 52% of patients treated with higherdose SRS (18-20 Gy) and in 16% treated with lower-dose SRS (<18 Gy).
The evidence related to the use of SRS for AVM consists primarily of noncomparative cohort studies, which demonstrate relatively high rates of complete obliteration of AVM after SRS, in the range of approximately 40% in some studies to greater than 70% in others. Isolating the effect of the SRS therapy in and of itself can be challenging, as many patients are treated with more than one therapy, including endovascular treatments and surgery. Recently, an RCT that compared medical therapy to a variety of interventions in the treatment for AVM showed no significant improvement in outcomes with interventional therapy. However, given that the interventional therapies included a variety of therapies, it is difficult to assess whether one particular component of the intervention has benefit or lacks benefit. Longer-term follow up will be forthcoming from this study.
Epilepsy
In the most recent literature review (2014), no new comparative studies evaluating SRS for the treatment of epilepsy were identified.
The currently-available research related to the use of SRS for epilepsy treatment is preliminary. There is inadequate information to determine the risk: benefit ratio of SRS compared with other therapies for epilepsy treatment.
Tremor
SRS has been used to for the treatment of tremor through stereotactic radiofrequency thalamotomy. In 2008, Kondziolka et al reported outcomes for 31 patients who underwent SRS thalamotomy for disabling essential tremor (Kondziolka, 2008). Among 26 patients with follow-up data available, score on the Fahn-Tolosa-Marin tremor score improved compared with baseline from 3.7 (pre-SRS) to 1.7 (post-SRS; P=<0.000015) and score on the Fahn-Tolosa-Marin handwriting score improved compared with baseline from 2.8 (pre-SRS) to 1.7 (post-SRS; P<0.0002). One patient developed transient mild right hemiparesis and dysphagia and one patient developed mild right hemiparesis and speech impairment.
Kooshkabadi et al reported outcomes for 86 patients with tremor treated over a 15 year period, including 48 with essential tremor, 27 with Parkinson disease, and 11 with multiple sclerosis (Kondziolka, 2013). Fahn-Tolosa-Marin tremor scores were used to compare symptoms pre- and post-procedure: the mean tremor score improved from 3.28 (pre-SRS) to 1.81 (post-SRS; P<0.0001), the mean handwriting score improved from 2.78 (pre-SRS) to 1.62 (post-SRS; P<0.0001), and the mean drinking score improved from 3.14 (pre- SRS) to 1.8 (post-SRS, P<0.0001). Complications included temporary hemiparesis in 2 patients, dysphagia in 1 patient, and sustained facial sensory loss in 1 patient.
Lim et al reported outcomes for a small cohort of 18 patients who underwent SRS treatment for essential tremor (Lim. 2010). For the 14 patients with videotaped evaluations allowing blinded evaluation of tremor severity and at least 6 months of follow up (N=11 with essential tremor and N=3 with Parkinson disease), Fahn-Tolosa-Marin Tremor Rating Scale activities of daily living scores improved significantly after SRS (mean change score 2.7 points; P = .03). However, there was no significant improvement in other Fahn-Tolosa-Marin Tremor Rating Scale items (P=0.53 for resting tremor, P= 0.24 for postural tremor, P=0.62 for action tremor, P=0.40 for drawing, P >.99 for pouring water, P= 0.89 for head tremor). Mild neurologic complications occurred in 2 patients (lip and finger numbness), and severe neurologic complications occurred in 1 patient (edema surrounding thalamic lesion with subsequent hemorrhage at the lesion site, with speech difficulty and hemiparesis.)
Ohye et al conducted a prospective study of SRS for tremor that included 72 patients, 59 with Parkinson disease and 13 with essential tremor) (Ohye, 2012). Among 52 patients who had follow up at 24 months, tremor scores measured using the unified Parkinson’s disease rating scale (P<0.001; approximate score decrease extrapolated from graph from 1.5 at baseline to 0.75 at 24 months follow up).
Young et al reported outcomes for a cohort of 158 patients with tremor who underwent SRS, including
102 patients with Parkinson’s disease, 52 with essential tremor, and 4 with tremor due to other conditions (Young, 2000). Among patients with a parkinsonian tremor, at latest follow up (mean 47 months), blinded assessments on unified Parkinson’s disease rating scale demonstrated improvements in several specific items, including overall tremor (from 3.3 pre-treatment to 1.2 at last follow-up; P<0.05) and action tremor (from 2.3 pre-treatment to 1.3 at last follow-up; P<0.05. Among patients with Essential tremor, blinded assessments were conducted using the Fahn-Tolosa-Marin Tremor Rating Scale. At 1 year of follow up,
92.1% of patients with essential tremor were completely or nearly tremor-free. Improvements were reported in components of the Fahn-Tolosa-Marin Tremor Rating Scale, but statistical comparisons are not presented. Three patients developed new neurological symptoms attributed to the SRS.
The evidence related to the use of SRS for tremor consists of uncontrolled cohort studies, many of which report outcomes from the treatment of tremor of varying etiologies. Most studies report improvements in standardized tremor scores, although few studies used a blinded evaluation of tremor score, allowing for bias in assessment. No studies that compared SRS to alternative methods of treatment or a control group were identified. Limited long-term follow up is available, making the long-term risk: benefit ratio of an invasive therapy uncertain.
Central Nervous System Neoplasms
Acoustic Neuromas
SRS is widely used for the treatment of acoustic neuromas (vestibular schwannomas). Case series report generally high rates of local control. For example, Badahshi et al reported a 3-year local tumor control rate of 88.9% in a study of 250 patients with vestibular schwannoma who underwent SRS or fractionated SRS (Badakhshi, 2014). Williams et al reported rates of tumor progression-free survival for patients with large vestibular schwannomas treated with SRS of 95.2% and 81.8% at 3 and 5 years, respectively (Williams, 2013). For patients with small vestibular schwannomas treated with SRS, tumor progression-free survival was 97% and 90% at 3 and 5 years, respectively. In a retrospective case series of 93 patients with vestibular schwannomas treated with SRS, 83 of whom had long-term follow up, Woolf et al. reported an overall control rate of 92% at a median follow up of 5.7 years. A small study from 2006 that compared microsurgical resection (N=36) with SRS (N=46) for the management of small (<3 cm) vestibular schwannomas showed better hearing preservation at last follow up in the SRS group (P<0.01) and no difference in tumor control between the groups (100% vs 96%, P=0.50) (Pollock, 2006).
The evidence related to the use of SRS for acoustic neuroma (vestibular schwannoma) consists primarily of case series and cohort studies, which report high rates of freedom from tumor progression. Given that vestibular schwannoma is a slow-growing tumor with symptoms most often related to local compression, demonstration of slowing of progression is a reasonable outcome. A single comparative study was identified that demonstrated comparable tumor control outcomes between SRS and surgical therapy for small vestibular schwannomas.
Craniopharyngioma
The evidence related to the use of SRS for craniopharyngioma consists primarily of case series and cohort studies, which report high rates overall survival. There is a lack of comparative studies evaluating the treatment of pituitary adenomas with SRS versus surgery or traditional radiotherapy.
Glomus Jugulare Tumors
The evidence review related to the use of SRS for glomus jugulare tumors identified includes a large meta-analysis, which suggested that SRS treatment is associated with improved patient outcomes.
Pituitary Adenoma
In 2013, Chen et al reported results from a systematic review and meta-analysis of studies evaluating SRS (specifically gamma-knife surgery) for the treatment of nonfunctioning pituitary adenoma that included a volumetric classification (Chen, 2013). Seventeen studies met the inclusion criteria, including 7 prospective cohort studies and 10 retrospective cohort studies, with 925 patients included in the meta-analysis. Outcomes were reported related to the rate of tumor control, rate of radiosurgery-induced optic neuropathy injury, and the rate of radiosurgery-induced endocrinologic deficits. In patients with tumor volume <2mL, the rate of tumor control was 99% (95% CI 96 to 100%), the rate of radiosurgery-induced optic neuropathy injury was 1% (95% CI 0 to 4%), and the rate of radiosurgery-induced endocrinologic deficits was 1% (95% CI 0 to 4%). In patients with volumes from 2 to 4 mL, the comparable rates were 96% (95% CI 92 to 99%), 0 (95% CI 0 to 2%), and 7% (95% CI 2 to 14%), respectively, and in patients with volumes larger than 4 mL was 91% (95% CI 89 to 94%), 2% (95% 0 to 5%) and 22% (95% CI 14- 31%), respectively. The rates of tumor control and rates of radiosurgery-induced optic neuropathy injury differed significantly across the three groups.
In 2014, Lee et al retrospectively reported outcomes for 41 patients treated with SRS in a cohort of 569 patients treated for nonfunctioning pituitary adenomas at three institutions (Lee, 2014). At a median follow up of 48 months, on neuroimaging 34 patients (82.9%) had a decrease in tumor volume, 4 patients had tumor stability (9.8%), and 3 patients had a tumor increase (7.3%). Progression-free survival was 94% at 5 years and 85% at 10 years post-SRS. New onset or worsened pituitary deficiencies were found in 10 patients (24.4%) at a median follow up of 52 months. The authors conclude that initial treatment with SRS for nonfunctioning pituitary adenomas may be appropriate in certain clinical settings, such as in older patients (70 or more years); in patients with multiple comorbidities in whom an operation would involve a high risk; in patients with clear neuroimaging and neuro-endocrine evidence of an NFA, no mass effect on the optic apparatus, and progressive tumor on neuroimaging follow-up; or in patients who wish to avoid resection. Sheehan et al reported results from a multicenter registry of 512 patients who underwent SRS for nonfunctional pituitary adenomas (Sheehan, 2013). Four hundred seventy-nine (93.6%) had undergone prior resection, and 34 (6.6%) had undergone prior external-beam radiotherapy. Median follow up was 36 months. At last follow up, 31 of 469 patients with available follow up (6.6%) had tumor progression, leading to an actuarial progression-free survival of 98%, 95%, 91%, and 85% at 3, 5, 8, and 10 years post-SRS, respectively. Forty-one (9.3%) of 442 patients had worsened or new CNS deficits, more commonly in patients with tumor progression (P=0.038).
Noncomparative studies demonstrate high rates of tumor control (85% and better) for pituitary adenomas with SRS treatment, with better tumor control with smaller lesions. There is a lack of comparative studies evaluating the treatment of pituitary adenomas with SRS versus surgery or traditional radiotherapy.
Randomized Controlled Trials
Since the publication of the systematic reviews, several RCTs have been published.
Nonrandomized, Comparative Studies
Tian et al reported results from a retrospective, single-institution cohort study comparing neurosurgical resection to SRS for solitary brain metastases from NSCLC. Seventy-six patients were included, 38 of whom underwent neurosurgery (Tian, 2013). Median survival was 14.2 months for the SRS group and 10.7 months for the neurosurgery group. In multivariable analysis, treatment mode was not significantly associated with differences in OS.
Noncomparative Studies
Noncomparative studies continue to evaluate the use of SRS without WBRT for the management of brain metastases, and the role of SRS for the management of larger numbers of brain metastases. Yamamoto et al conducted a prospective observational study to evaluate primary SRS in patients with 1-10 newly diagnosed brain metastases (Yamamoto, 2014). Inclusion criteria included largest tumor volume less than 10 mL and less than 3 cm in the longest diameter, a total cumulative volume less than or equal to 15 mL, and a Karnofsky performance status score of 70 or higher. Among total 1,194 patients, the median OS after SRS was 13.9 (95% CI 12.0 to 15.6) in the 455 patients with 1 tumor, 10.8 months (95% CI 9.4 to 12.4) in the 531 patients with 2-4 tumors, and 10.8 months (95% CI 9.1 to 12.7) in the 208 patients with 5-10 tumors. Rava et al, in a cohort study including 53 patients with at least 10 brain metastases, described the feasibility of SRS treatment ((Rava, 2013). Median survival was 6.5 months in this cohort. Raldow et al, in a cohort of 103 patients with at least 5 brain metastases who were treated with SRS alone, demonstrated a median OS of 8.3 months, comparable to historical controls.46 OS was similar for patients with 5-9 and with at least 10 metastases (7.6 months and 8.3 months, respectively).
Yomo et al reported outcomes for 41 consecutive patients with 10 or fewer brain metastases from NSCLC who received SRS as primary treatment (Yomo, 2014). The study reported 1- and 2-year OS rates of 44% and 17%, respectively, with a median survival time of 8.1 months. Distant brain metastases occurred in 44% by 1 year, with 18 patients requiring repeat SRS, 7 requiring WBRT, and 1 requiring microsurgery.
For cases of brain metastases, evidence from RCTs and systematic reviews indicates that the use of
SRS improves outcomes in the treatment of brain metastases. SRS appears to be feasible in the treatment of larger numbers (e.g. >10) of brain metastases, and outcomes after SRS treatment do not appear to be worse for patients with larger numbers of metastases, et least for patients with 10 or fewer metastases.
Uveal Melanoma
Since the publication of the 2012 review, several studies have reported outcomes from SRS for intraocular melanoma. Wackernagel et al reported outcomes for 189 patients with choroidal melanoma treated with SRS (Gamma Knife) (Wackernagel, 2014). All patients with choroidal melanoma at the authors’ institution were offered SRS as an alternative to enucleation if they wished to retain their eye, and other globe-preserving treatment options were not feasible because of tumor size or location or the patient’s general health. Sixty-six patients (37.3%), all treated before 2003, received high-dose SRS (35-80 Gy); subsequently, all patients received low-dose SRS (30 Gy in 87 patients and 25 Gy in 24 patients). The median overall follow-up was 39.5 months. During follow-up, local tumor control was achieved in 167 patients (94.4%). Enucleation was required in 25 patients, 7 due to tumor reoccurrence and 18 due to radiation-induced adverse effects. Overall survival and distant metastasis rates are not reported.
Furdova et al reported outcomes for a cohort of 96 patients who underwent SRS at a single center in Slovakia for stage T2/T3 uveal melanoma (Furdova, 2014). Local tumor control occurred in 95% of patients at 3 years of follow up and in 85% of patients at 5 years of follow up. Eleven patients (11.5%) required secondary enucleation between 3 and 5 years post-SRS due to radiation neuropathy or secondary glaucoma.
The evidence related to SRS for the treatment of uveal melanoma is limited to case series. The published literature is insufficient to demonstrate improved outcomes with the use of stereotactic radiosurgery over other accepted radiation modalities in the treatment of uveal melanoma.
Stereotactic Body Radiation Therapy
Spinal Tumors
Sahgal et al evaluated rates of vertebral compression fractures after SBRT in 252 patients with 410 spinal segments treated with SBRT (Shagal, 2013). Fifty-seven fractures were observed (13.9% of spinal segments treated), with 27 de novo fractures and 30 cases of existing fracture progression. Most fractures occurred relatively early post-treatment, with a median and mean time to fracture of 2.46 months and 6.33 months, respectively. Radiation dose per fraction, baseline vertebral compression fracture, lytic tumor, and baseline spinal misalignment were predictive of fracture risk.
Non-Small-Cell Lung Cancer
Systematic Reviews
In 2014, Zheng et al reported results from a systematic review and meta-analysis comparing survival afterSBRT with survival after surgical resection for the treatment of stage I NSCLC (Zheng, 2014). The authors included 40 studies reporting outcomes from SBRT, including 4850 patients, and 23 studies reporting outcomes after surgery published in the same time period, including 7071 patients. For patients treated with SBRT, the mean unadjusted OS rates at 1, 3, and 5 years were 83.4%, 56.6%, and 41.2%, respectively. The mean unadjusted OS rates at 1, 3, and 5 years were 92.5%, 77.9%, and 66.1%, respectively, with lobectomy, and 93.2%, 80.7%, and 71.7% with limited lung resections. After adjustment for surgical eligibility (for the 27 SBRT studies which reported surgical eligibility) and age, in a multivariable regression model, the treatment modality (SBRT vs surgical therapy) was not significantly associated with OS (P=0.36).
Nonrandomized, Comparative Studies
In a matched-cohort study design, Crabtree et al retrospectively compared outcomes between SBRT and surgical therapy in patients with stage 1 NSCLC (Crabtree, 2014). Four hundred fifty-eight patients underwent primary surgical resection and 151were treated with SBRT. Surgical and SBRT patients differed significantly on several baseline clinical and demographic characteristics, with SBRT patients having an older mean age, higher comorbidity scores, a greater proportion of peripheral tumors, and worse lung function at baseline. For the surgical group, 3-year OS and disease-free survival were 78% and 72%, respectively. Of note, among the 458 patients with clinical stage I lung cancer, 14.8% (68/458) were upstaged at surgery and found to have occult N1 or N2 disease. For patients with occult nodal disease, 3-year and 5-year OS were 66% and 43%, respectively. For patients without occult nodal disease, 3- and 5-year OS were 80% and 68%, respectively. For the SBRT group, 3-year OS and disease-free survival were 47% and 42%, respectively.
In a propensity score-matched analysis, 56 patients were matched based on clinical characteristics, including age, tumor size, ACE comorbidity score, FEV1%, and tumor location (central versus peripheral). In the final matched comparison, 3-year overall survival was 52% versus 68% for SBRT and surgery, respectively (P=0.05), while disease-free survival was 47% versus 65% (P=0.01). Two-, 3-, 4-, and 5-year local recurrence-free survival for SBRT was 91%, 91%, 81%, and 40%, respectively, versus 98%, 92%, 92%, and 92% for surgery (P=0.07).
Jepperson et al compared SBRT with conventional radiation therapy for patients with medically inoperable NSCLC (T1-2N0M0) (Jeppesen, 2013). The study included 100 subjects treated with SBRT and 32 treated with conventional radiation therapy. At baseline, the SBRT-treated patients had smaller tumor volume, lower FEV1, and a greater proportion of T1 stage disease. The median overall survival was 36.1 months versus 24.4 months for SBRT and conventional RT, respectively (p =0.015). Local failure-free survival rates at one year were in SBRT group 93% versus 89% in the conventional RT group and at five years 69% versus 66%, SBRT and conventional RT respectively (P =0.99).
Port et al compared SBRT with wedge resection for patients with clinical stage IA NSCLC using data from a prospectively maintained database (Port, 2014). One hundred sixty-four patients were identified, 99 of whom were matched based on age, sex, and tumor histology. Thirty-eight patients underwent a wedge resection only, 38 patients underwent a wedge resection with brachytherapy, and 23 patients had SBRT. SBRT patients were more likely to have local or distant recurrences than surgically-treated patients (9% vs 30%, P=0.016), but there were no differences between the groups in disease-free 3-year survival (77% for wedge resection vs 59% for SBRT, P=0.066).
Varlotta et al compared surgical therapy (N=132 with lobectomy and N=48 with sublobar resection) with SBRT (N=137) in the treatment of stage I NSCLC.67 Mortality was 54% in the SBRT group, 27.1% in the sublobar resection group, and 20.4% in the lobar resection group. After matching for pathology, age, sex, tumor diameter, aspirin use, and Charlson comorbidity index, patients with SBRT had lower OS than patients treated with either wedge resection (P=0.003) or lobectomy (P<0.0001).
Noncomparative Studies
In a prospective evaluation of 185 medically inoperable patients with early (T1-T2N0M0) NSCL treated with SBRT, Allibhai et al evaluated the influence of tumor size on outcomes (Allibhai, 2013). Over a median follow up of 15.2 months, tumor size (maximum gross tumor diameter) was not associated with local failure but was associated with regional failure (P=0.011) and distant failure (P=0.021). Poorer overall survival (P=0.001), disease-free survival (P=9.001), and cause-specific survival (P=0.005) were also significantly associated with tumor volume more significant than diameter.
Noncomparative Studies
Yoon et al reported outcomes for 93 patients with primary non-metastatic HCC treated with SBRT at a single institution (Yoon, 2013). The median follow up was 25.6 months. OS at 1 and 3 years was 86% and 53.8%, respectively. The main cause of treatment failure was intrahepatic (i.e., out-of-field) metastases. At 1 and 3 years, local control rates were 94.8% and 92.1%, respectively, and distant metastasis-free survival rates were 87.9% and 72.2%, respectively. However, intrahepatic recurrence-free survival rates at 1 and 3 years were 51.9% and 32.4%, respectively.
Jung et al reported rates of radiation-induced liver disease in patients with HCC treated with SBRT for small (<6 cm), non-metastatic HCC that was not amenable to surgery or percutaneous ablative therapy (Jung, 2014). Ninety-two patients were included, 17 of whom (18.5%) developed grade 2 or worse radiation-induced liver disease within 3 months of SBRT. In multivariable analysis, Child-Pugh class was the only significant predictor of radiation-induced liver injury. The 1- and 3-year survival rates were 86.9% and 54.4% respectively; with the median survival of 53.6 months. The presence of radiation-induced liver disease was not associated with survival.
Prostate Cancer
2023 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2023. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
China et al published a systematic review examining the efficacy and safety of Gamma knife radiosurgery for cerebral AVMs (China, 2022). A total of 34 cohort studies (N=8673) with a median follow up of 60 months were identified. The studies included were at moderate risk of bias because none of them were randomized and none concealed treatment allocation. The pooled obliteration rate following single-session SRS for cerebral AVMs was 56.7% in 21 cohorts that confirmed obliteration by angiography alone and 67.8% in 29 cohorts that confirmed obliteration by either angiography or magnetic resonance imaging (MRI). For cohorts with a follow up of at least 2 years, the median obliteration rate was 63.5% and 70.85%, respectively, for obliteration confirmed by angiography or a selection of either angiography or MRI. The authors noted there is a risk of over-estimation of the true obliteration rate when MRI is used to confirm obliteration compared to angiography.
Savardekar et al published a systematic review comparing SRS with microsurgery with regard to hearing preservation, tumor control, and facial nerve dysfunction in patients undergoing primary treatment for small to medium (<3 cm) sporadic vestibular Schwannomas (Savardekar, 2022). Microsurgery resulted in 56% hearing preservation, 98% tumor control, and 10% facial nerve dysfunction. Stereotactic radiosurgery resulted in 59% hearing preservation, 92% tumor control, and 2% facial nerve dysfunction.
Ong et al completed a systematic review evaluating SRS for patients with glomus jugulare tumors; the review did not compare SRS to other treatment modalities (Ong, 2022). 23 studies (N=460) were identified. The average follow-up across studies was 47 months (range, 4 to 268 months). The pooled tumor control rate after SRS was 95% (95% CI, 93 to 97). Rates of tinnitus, hearing loss, and lower cranial nerve improvement after treatment were 54%, 28%, and 22%, respectively.
Garsa et al conducted a systematic review of available evidence comparing WBRT and SRS alone or in combination, as initial or postoperative treatment, with or without systemic therapy for adults with brain metastases due to lung cancer, breast cancer, or melanoma (Garsa, 2021). Despite the identification of 97 studies, statistical analyses were limited due to heterogeneity across the available data. Based on pooled data from 4 RCTs, there was no statistically significant difference in OS when comparing SRS plus WBRT to SRS alone or to WBRT alone (HR, 1.09; 95% CI, 0.69 to 1.73). Based on pooled data from 3 RCTs, OS did not differ when comparing postsurgical WBRT to postsurgical SRS (HR, 1.17; 95% CI, 0.61 to 2.25). Lastly, pooled data from 4 RCTs did not show a significant difference in the risk of serious adverse events with WBRT plus SRS versus WBRT or SRS alone (RR, 1.05; 95% CI, 0.12 to 8.89).
Hartgerink et al conducted an RCT comparing WBRT to SRS in Dutch patients with 4 to 10 brain metastases (Hartgerink, 2021). The study was prematurely stopped due to poor accrual, but prior to that, 15 patients were randomized to receive SRS and 14 patients to WBRT. The median number of lesions was 6 (range, 4 to 9). Results demonstrated a 1-year actutimes survival rate of 57% with SRS and 31% with WBRT (p=.52). The actutimes 1-year brain salvage-free survival rate was 50% with SRS and 78% with WBRT (p=.22). In a separate publication describing QOL outcomes in 20 patients 3 months post-treatment, SRS demonstrated favorable outcomes compared to WBRT for the following EuroQol- 5 Dimension domains: mobility (p=.041), self-care (p=.028), and alopecia (p=.014) (Hartgerink, 2022).
Guleser et al retrospectively evaluated patients with uveal melanoma who were treated with either brachytherapy (n=201) or Gamma knife radiosurgery (n=52) at a single center in Turkey (Guleser, 2022). The median follow-up time was 45 months for the brachytherapy group and 56 months for the SRS group. The OS at 5 years was 88% and 89% for patients in the SRS and brachytherapy groups, respectively. Local recurrence occurred in 13% of patients in the SRS group and in 7% of patients in the brachytherapy group (p=.13). Eye retention was more likely with brachytherapy compared to SRS (95% vs 81%; p<.001) and vision loss was more likely with SRS compared to brachytherapy (60% vs 44%; p=.048).
Sahgal et al compared complete response rates for pain after SBRT (n=114) or EBRT (n=115) in patients with painful spinal metastasis enrolled in an open-label, multicenter, RCT performed at 13 hospitals in Canada and 5 in Australia (Sahgal, 2021). Patients were eligible if they had painful (defined as ≥2 points with the Brief Pain Inventory) MRI-confirmed spinal metastasis, ≤3 consecutive vertebral segments to be included in the treatment volume, an Eastern Cooperative Oncology Group performance status (ECOG PS) of ≤2, and no neurologically symptomatic spinal cord or cauda equina compression. The primary endpoint was the proportion of patients with complete response for pain at 3 months after radiotherapy. At baseline, approximately 75% of enrolled patients were radiosensitive and 25% were radioresistant. Results demonstrated that significantly more patients who received SBRT compared to EBRT achieved the primary endpoint (35% vs 14%; risk ratio, 1.33; 95% CI, 1.14 to 1.55; p=.0002).
Ito et al reported on the outcomes for 33 patients with metastatic epidural spinal cord compression who underwent separation surgery and SBRT and were followed prospectively for a median duration of 15 months (range, 3 to 35 months) (Ito, 2022). Approximately 25% of enrolled patients were treated with radiotherapy in the past. The 1-year local failure rate was 13% (95% CI, 4 to 27) and the 1-year OS rate was 79%. Complete or partial pain response at 1, 3, 6, 9, and 12 months was 82%, 92%, 80%, 74%, and 83%, respectively.
Zhang et al published a systematic review of 87 studies involving SBRT (n=12,811) and 18 studies involving RFA (n=1,535) for patients with inoperable stage I NSCLC (Zhang, 2022). The local control rates with SBRT were 98%, 95%, 92%, and 92%, respectively, at 1, 2, 3, and 5 years; the local control rates for RFA were significantly lower (75%, 31%, 67%, and 41%, respectively, at 1, 2, 3, and 5 years; p<.01 for all comparisons). The OS rates were similar between SBRT and RFA at 1 year (87% vs 89%, respectively; p=.07) and 2 years (71% vs 69%, respectively; p=.42), whereas the OS was significantly improved with SBRT over RFA at 3 years (58% vs 48%; p<.01) and 5 years (39% vs 21%; p<.01). The most common complication of SBRT was radiation pneumonitis (9.1%), whereas pneumothorax was the most common complication of RFA (27.2%).
Shanker et al conducted a meta-analysis of 48 cohort studies (mainly retrospective) assessing the rates of OS and local control in 2846 patients with primary HCC (Shanker, 2021). Comparisons to other treatment Modalities were not made. Pooled 1-, 2- and 3-year OS rates were 78.4%, 61.3%, and 48.3%, respectively. Rates of local control rates at 1-, 2- and 3-years were 91.1%, 86.7%, and 84.2%, respectively.
Ji et al compared SBRT to RFA in 60 patients with unresectable HCC at a single center in Japan (Ji, 2022). There were 22 cases treated by SBRT and 38 cases by RFA. The complete remission rate at 3 months was similar in both SBRT and RFA groups (81.8% and 89.4%, respectively), as was the local tumor control rate (90.9% and 94.7%, respectively). The 1-year and 2-year rates of OS were 88.2% and 85.7% in the SBRT group and 100% and 75% in the RFA group, respectively; the differences between treatment groups did not reach statistical significance. Extrahepatic recurrence occurred in 6 patients in the SBRT group and no patients in the RFA group (p<.001).
Hannan et al assessed the efficacy of SBRT in 20 patients with metastatic RCC who developed growth of 3 or fewer tumors while receiving first- to fourth-line systemic therapy (Hannan, 2022). Results demonstrated a local control rate of 100%; the OS was not reached. At a median follow-up of 10.4 months, SBRT extended the duration of the ongoing systemic therapy by more than 6 months in 14 patients. The median time from SBRT to the onset of new systemic therapy or death was 11.1 months.
Cheung et al assessed the efficacy of SBRT in 37 patients with metastatic RCC who developed growth of 5 or fewer tumors while receiving oral TKI therapy for at least 3 months (Cheung, 2021). Results demonstrated a 1-year local control rate of 93% after SBRT, a median PFS of 9.3 months (95% CI, 7.5 to 15.7), and a 1-year OS rate of 92% (95% CI, 82 to 100). The cumulative incidence of changing systemic therapy was 47%, with a median time to change in systemic therapy of 12.6 months.
In 2021, the American Society of Clinical Oncology (ASCO), Society for NeuroOncology (SNO), and the American Society for Radiation Oncology (ASTRO) published a guideline that addresses the role of surgery, radiation therapy, and systemic therapy in the treatment of patients with brain metastases secondary to nonhematologic solid tumors (Vogelbaum, 2022). The following recommendations regarding the use of SRS in this population were made in this guideline:
In 2022, ASTRO published an evidence-based guideline on indications and techniques for external beam radiation therapy (EBRT) in patients with primary liver cancers (Apisarnthanarax, 2022). SBRT (also referred to as ultrahypofractionation delivered in ≤5 fractions) was among the EBRT techniques discussed for patients with confirmed HCC and intrahepatic cholangiocarcinoma (IHC). The choice of regimen is based on tumor location, underlying liver function, and available technology.
International Stereotactic Radiosurgery Society (ISRS) guideline and practice opinions:
Arteriovenous Fistulas: SRS is recommended for patients with "complex dural arteriovenous fistula who are planned for embolization and are at high risk for not achieving complete obliteration with embolization alone; dural arteriovenous fistula who have received previous embolization without complete obliteration and have refractory symptoms; high-risk noncavernous sinus dural arteriovenous fistula or symptomatic cavernous sinus dural arteriovenous fistula who are not candidates for or have refused both embolization or microsurgery" (Singh, 2022).
Postoperative spine malignancy: "Postoperative spine SBRT delivers a high 1-year local control with acceptably low toxicity. Patients who may benefit from this include those with oligometastatic disease, radioresistant histology, paraspinal masses, or those with a history of prior irradiation to the affected spinal segment...the ISRT recommends a minimum interval of 8 to 14 days after invasive surgery before simulation for SBRT, with initiation of radiation therapy within 4 weeks of surgery" (Faruqi, 2022).
Secretory pituitary adenomas: "SRS is an effective option to control growth of GH-, ACTH-, & PRL-secreting residual or recurrent pituitary adenomas after prior surgical resection but offers lower rate of endocrine improvement or remission." "SRS could also be used as primary therapy for GH- and ACTH-secreting pituitary adenomas in patients deemed medically unfit for surgical resection, or as an alternative to surgical resection for PRL-secreting pituitary adenomas unresponsive to dopaminergic agonists." "Withdrawal of antisecretory medications is preferred, typically for 4 to 12 weeks prior to radiosurgery, if safely possible considering endocrinologic status of patient" (Mathieu, 2022).
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1994 Blue Cross Blue Shield Association Technology Evaluation Center Assessment; Tab 38. 1995 Blue Cross Blue Shield Association Technology Evaluation Center Assessment; Tab 5. 1995 Blue Cross Blue Shield Association Technology Evaluation Center Assessment; Tab 6. 1995 Blue Cross Blue Shield Association Technology Evaluation Center Assessment; Tab 7. 1997 Blue Cross Blue Shield Association Technology Evaluation Center Assessment; Tab 24. 1998 Blue Cross Blue Shield Association Technology Evaluation Center Assessment; Tab 28. Adler JR, Cox RS, Kaplan I, et al.(1992) Stereotactic Radiosurgical Treatment of Brain Metastases. J Neurosurg 1992; 76:444-449. Ahmed KA, Barney BM, Macdonald OK, et al.(2013) Stereotactic body radiotherapy in the treatment of adrenal metastases. Am J Clin Oncol. Oct 2013;36(5):509-513. PMID 22781389 Alexander E, Coffey R, Loeffler JS.(1993) Radiosurgery for Gliomas. Stereotactic RadioSurg 1993; McGraw-Hill; Alexander E, Loeffler JS and Lunsford LD (Ed's), New York; 307-219. Alexander E, Loeffler JS.(1992) Radiosurgery Using a Modified Linear Accelerator. Neurosurg Clin N Am 1992; 3:167-190. Alexander H, Moriarty TM, David RB, et al.(1995) Stereotactic Radiosurgery for the Definitive, Noninvasive Treatment of Brain Metastases. J Oncol 1995; 87:34-40. Allibhai Z, Taremi M, Bezjak A, et al.(2013) The impact of tumor size on outcomes after stereotactic body radiation therapy for medically inoperable early-stage non-small cell lung cancer. Int J Radiat Oncol Biol Phys. Dec 1 2013;87(5):1064-1070. PMID 24210082 Alongi F, Arcangeli S, Filippi AR et al.(2012) Review and uses of stereotactic body radiation therapy for oligometastases. The oncologist 2012; 17(8):1100-7. Aoyama H, Shirato H, et al.(2006) Stereotactic radiosurgery plus whole-brain radiation therapy vs stereotactic radiosurgery alone for treatment of brain metastases: a randomized controlled trial. JAMA, 2006; 295:2483-91. Apisarnthanarax S, Barry A, Cao M, et al(2022) External Beam Radiation Therapy for Primary Liver Cancers: An ASTRO Clinical Practice Guideline Pract Radiat Oncol Jan-Feb 2022; 12(1): 28-51 PMID 34688956 Attanasio R, Epaminonda P, et al.(2003) Gamma-knife radiosurgery in acromegaly: A 4-year follow-up study. J Clin Endocrin Metab 2003; 88:3105-12. Badakhshi H, Muellner S, Wiener E, et al.(2014) Image-guided stereotactic radiotherapy for patients with vestibular schwannoma. A clinical study. Strahlenther Onkol. Jun 2014;190(6):533-537. PMID 24589920 Balaban EP, Mangu PB, Khorana AA, et al.(2016) Locally Advanced, Unresectable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. Aug 01 2016; 34(22): 2654-68. PMID 27247216 Barnett GH, Linskey ME, et al.(2007) Stereotactic radiosurgery - an organized neurosurgery-sanctioned definition. J Neurosurg, 2007; 105:1-5. Ben-Josef B, Lawrence TS.(2009) Using a Bigger hammer: The Role of Stereotactic Body Radiotherapy in the Management of Oligometastases. J Clinical Oncology 2009; 27:1537-1539. Bittner MI, Grosu AL and Brunner TB.(2015) Comparison of toxicity after IMRT and 3D-conformal radiotherapy for patients with pancreatic cancer – A systemic review. Radiother Oncol. 2015; 114:117-21. Bolzicco G, Favretto MS, Satariano N, et al.(2013) A single-center study of 100 consecutive patients with localized prostate cancer treated with stereotactic body radiotherapy. BMC Urol. 2013;13:49. PMID 24134138 Bowden G, Kano H, Tonetti D, et al.(2014) Stereotactic radiosurgery for arteriovenous malformations of the cerebellum. J Neurosurg. Mar 2014;120(3):583-590. PMID 24160482 Brand DH, Tree AC, Ostler P et al. PACE Trial Investigators(2019) Intensity-modulated fractionated radiotherapy versus stereotactic body radiotherapy for prostate cancer (PACE-B): acute toxicity findings from an international, randomised, open-label, phase 3, non-inferiority trial. Lancet Oncol. 2019;20(11):1531. Bujold A, Massey CA, Kim JJ et al.(2013) Sequential phase I and II trials of stereotactic body radiotherapy for locally advanced hepatocellular carcinoma. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2013; 31(13):1631-9. Cabrera AR, Cuneo KC, Desjardins A, et al.(2013) Concurrent stereotactic radiosurgery and bevacizumab in recurrent malignant gliomas: a prospective trial. Int J Radiat Oncol Biol Phys. Aug 1 2013;86(5):873-879. PMID 23725997 Cabrera AR, Kirkpatrick JP, Fiveash JB, et al.(2016) Radiation therapy for glioblastoma: Executive summary of an American Society for Radiation Oncology Evidence-Based Clinical Practice Guideline. Pract Radiat Oncol. Jul-Aug 2016;6(4):217-225. PMID 27211230 Caron JL, Souhami I, Podgorsak EB.(1992) Dynamic Stereotactic Radiosurgery in the Palliative Treatment of Cerebral Metastatic Tumors. J Neuro-Oncol 1992; 12; 173-179. Casamassima F, Livi L, Masciullo S et al.(2012) Stereotactic radiotherapy for adrenal gland metastases: university of Florence experience. International journal of radiation oncology, biology, physics 2012; 82(2):919-23. Chamberlain MC, Barba D, Lormanik P, et al.(1994) Stereotactic Radiosurgery for Recurrent Gliomas. Cancer 1994; 74:1342-1347. Chang DT, Swaminath A, Kozak M et al.(2011) Stereotactic body radiotherapy for colorectal liver metastases: a pooled analysis. Cancer 2011; 117(17):4060-9. Chang SD, Gibbs IC, et al.(2005) Staged stereotactic irradiation for acoustic neuroma. Neurosurgery, 2005; 56:1254-61, discussion 1261-3. Chawla S, Chen Y, Katz AW et al.(2009) Stereotactic body radiotherapy for treatment of adrenal metastases. International journal of radiation oncology, biology, physics 2009; 75(1):71-5. Chen LN, Suy S, Wang H, et al.(2014) Patient-reported urinary incontinence following stereotactic body radiation therapy (SBRT) for clinically localized prostate cancer. Radiat Oncol. 2014;9:148. PMID 24966110 Chen Y, Li ZF, Zhang FX, et al.(2013) Gamma knife surgery for patients with volumetric classification of nonfunctioning pituitary adenomas: a systematic review and meta-analysis. Eur J Endocrinol. Oct 2013;169(4):487-495. PMID 23904281 Cheung P, Patel S, North SA, et al(2021) Stereotactic Radiotherapy for Oligoprogression in Metastatic Renal Cell Cancer Patients Receiving Tyrosine Kinase Inhibitor Therapy: A Phase 2 Prospective Multicenter Study Eur Urol Dec 2021; 80(6): 693-700 PMID 34399998 China M, Vastani A, Hill CS, et al(2022) Gamma Knife radiosurgery for cerebral arteriovenous malformations: a systematic review and meta-analysis Neurosurg Rev Jun 2022; 45(3): 1987-2004 PMID 35178626 Chung HT, Ma R, et al.(2004) Audiologic and treatment outcomes after linear accelerator-based stereotactic irradiation for acoustic neuroma. Int J Rad Oncol Biol Phys, 2004; 59:1116-21. Clark GM, McDonald AM, Nabors LB, et al.(2014) Hypofractionated stereotactic radiosurgery with concurrent bevacizumab for recurrent malignant gliomas: the University of Alabama at Birmingham experience. Neurooncol Pract. Dec 2014;1(4):172-177. PMID 26034629 Coffey RJ, Casino TL, Shaw EG.(1993) Radiosurgical Treatment of Recurrent Mangiopericytomas of the Meninges: Preliminary Results. J NeuroSurg 1993; 78:903-908. Coffey RJ, Lunsford LD, Flickinger JC.(1992) The Role of Radiosurgery in the Treatment of Malignant Brain Tumors. Neurosurg Clin N Am 1992; 3:231-244. Coia LR, Aaronson N, Linggood R, et al.(1992) A Report of the Consensus Workshop Panel on the Treatment of Brain Metastases. Int J Radiat Oncol Biol Phys 1992; 23:223-227. Combs SE, Thilmann C, Huber PE et al.(2007) Achievement of long-term local control in patients with craniopharyngiomas using high precision stereotactic radiotherapy. Cancer 2007; 109(11):2308-14. Comito T, Cozzi L, Zerbi A, et al.(2017) Clinical results of stereotactic body radiotherapy (SBRT) in the treatment of isolated local recurrence of pancreatic cancer after R0 surgery: a retrospective study. Eur J Surg Oncol. 2017;43(4):735-42. Corbin KS, Hellman S, Weichselbaum RR.(2013) Extracranial oligometastases: a subset of metastases curable with stereotactic radiotherapy. J Clin Oncol 2013; 31(11):1384-90. Crabtree TD, Puri V, Robinson C, et al.(2014) Analysis of first recurrence and survival in patients with stage I non-small cell lung cancer treated with surgical resection or stereotactic radiation therapy. J Thorac Cardiovasc Surg. Apr 2014;147(4):1183-1191; discussion 1191-1182. PMID 24507980 Cuneo KC, Vredenburgh JJ, Sampson JH, et al.(2012) Safety and efficacy of stereotactic radiosurgery and adjuvant bevacizumab in patients with recurrent malignant gliomas. Int J Radiat Oncol Biol Phys. Apr 1 2012;82(5):2018- 2024. PMID 21489708 Curran WJ, Scott CB, Weinstein AS, et al.(1993) Survival Comparison of Radiosurgery-eligible and Ineligible Malignant Glioma Patients Treated With Hyperfractionated Radiation Therapy and Carmustine: a Report of Radiation Therapy Oncology Group 83-02. J Clin Oncol 1993; 11:857-862. De Maria L, Terzi di Bergamo L, Conti A, et al.(2021) CyberKnife for Recurrent Malignant Gliomas: A Systematic Review and Meta-Analysis. Front Oncol. 2021; 11: 652646. PMID 33854978 Deangelis LM.(1994) Management of Brain Metastases. Cancer Invest 1994; 12:156-165. Degen JW, Gagnon GJ, et al.(2005) CyberKnife stereotactic radiosurgical treatment of spinal tumors for pain control and quality of life. J Neurosurg Spine, 2005; 2:540-9. Dodoo E, Huffmann B, Peredo I, et al.(2014) Increased survival using delayed gamma knife radiosurgery for recurrent high-grade glioma: a feasibility study. World Neurosurg. Nov 2014;82(5):e623-632. PMID 24930898 Dunavoelgyi R, Dieckmann K, Gleiss A et al.(2011) Local tumor control, visual acuity, and survival after hypofractionated stereotactic photon radiotherapy of choroidal melanoma in 212 patients treated between 1997 and 2007. Int J Radiat Oncol Biol Phys 2011; 81(1):199-205. Eibl-Lindner K, Furweger C, Nentwich M, et al.(2016) Robotic radiosurgery for the treatment of medium and large uveal melanoma. Melanoma Res. Feb 2016;26(1):51-57. PMID 26484738 El-Ghanem M, Kass-Hout T, Kass-Hout O, et al.(2016) Arteriovenous Malformations in the Pediatric Population: Review of the Existing Literature. Interv Neurol. Sep 2016;5(3-4):218-225. PMID 27781052 El-Shehaby AM, Reda WA, Abdel Karim KM, et al.(2015) Gamma Knife radiosurgery for low-grade tectal gliomas Acta Neurochir (Wien). Feb 2015;157(2):247-256. PMID 25510647 Engerhart R, Kimmig BN, Hover KH, et al.(1993) Long-term Follow-up for Brain Metastases Treated by Percutaneous Stereotactic Single High-dose Irradiation. Cancer 1993; 71:1351-1361. Faruqi S, Chen H, Fariselli L, et al(2022) Stereotactic Radiosurgery for Postoperative Spine Malignancy: A Systematic Review and International Stereotactic Radiosurgery Society Practice Guidelines Pract Radiat Oncol Mar-Apr 2022; 12(2): e65-e78 PMID 34673275 Fedorcask I, Sipos L, Horvath A, et al.(1993) Multiple Intracranial Melanoma Metastases Treated With Surgery and Radiosurgery with Long Term Control. A Case Report. J Neuro-Oncology 1993; 16:173-176. Feng ES, Sui CB, Wang TX, et al.(2016) Stereotactic radiosurgery for the treatment of mesial temporal lobe epilepsy. Acta Neurol Scand. Dec 2016;134(6):442-451. PMID 26846702 Fernando HC, Timmerman R.(2012) American College of Surgeons Oncology Group Z4099/Radiation Therapy Oncology Group 1021: a randomized study of sublobar resection compared with stereotactic body radiotherapy for high-risk stage I non-small cell lung cancer. J Thorac Cardiovasc Surg. Sep 2012;144(3):S35-38. PMID 22795435 Flickinger JC, Kondziolka D, Lunsford LD, et al.(1994) A Multi institutional Experience with Stereotactic Radiosurgery for Solitary Brain Metastasis. Int J Radiat Oncol Biol Phys 1994; 28:797-802. Florell RC, MacDonald DR, Irish WD, et al.(1992) Selection Bias, Survival and Brachytherapy for Glioma. J Neurosurg 1992; 76:179-183. Foerster R, Zwahlen DR, Buchali A, et al.(2021) Stereotactic Body Radiotherapy for High-Risk Prostate Cancer: A Systematic Review. Cancers (Basel). Feb 12 2021; 13(4). PMID 33673077 Fokas E, Henzel M, Wittig A, et al.(2013) Stereotactic radiosurgery of cerebral arteriovenous malformations: long-term follow-up in 164 patients of a single institution. J Neurol. Aug 2013;260(8):2156-2162. PMID 23712798 Furdova A, Slezak P, Chorvath M et al.(2010) No differences in outcome between radical surgical treatment (enucleation) and stereotactic radiosurgery in patients with posterior uveal melanoma. Neoplasma 2010; 57(4):377-81. Furdova A, Sramka M, Chorvath M, et al.(2014) Stereotactic radiosurgery in intraocular malignant melanoma--retrospective study. Neuro Endocrinol Lett. 2014;35(1):28-36. PMID 24625918 Ganz JC, Backlund EO, Thorsen FA.(1993) The Results of Gamma Knife Surgery of Meningiomas, Related to Size of Tumor and Dose. Stereotactic Func Neurosurg 1993; 61:23-29. Garsa A, Jang JK, Baxi S, et al(2021) Radiation Therapy for Brain Metastases: A Systematic Review Pract Radiat Oncol Sep-Oct 2021; 11(5): 354-365 PMID 34119447 Gerszten PC, Burton SA, et al.(2007) Radiosurgery for spinal metastases: clinical experience in 500 cases from a single institution. Spine, 2007; 32:193-9. Gerszten PC, Ozhasoglu C, et al.(2004) CyberKnife frameless stereotactic radiosurgery for spinal lesions: clinical experience in 125 cases. Neurosurgery, 2004; 55: 89-98, discussion 00498-9. Goldsmith BJ, Wara WM, Wilson CB, et al.(1994) Postoperative Irradiation for Subtotally Resected Meningiomas: Retrospective Analysis of 140 Patients Treated from 1967-1990. J NeuroSurg 1994; 80:195-201. Gondi V, Bauman G, Bradfield L, et al.(2022) Radiation Therapy for Brain Metastases: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol. 2022; 12(4): 265-282. PMID 35534352 Graber JJ, Cobbs CS, Olson JJ.(2019) Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Use of Stereotactic Radiosurgery in the Treatment of Adults With Metastatic Brain Tumors. Neurosurgery. Mar 01 2019; 84(3): E168-E170. PMID 30629225 Graffeo CS, Sahgal A, De Salles A, et al.(2020) Stereotactic Radiosurgery for Spetzler-Martin Grade I and II Arteriovenous Malformations: International Society of Stereotactic Radiosurgery (ISRS) Practice Guideline. Neurosurgery. Sep 01 2020; 87(3): 442-452. PMID 32065836 Green SB, Shapiro WR, Burger PC, et al.(1994) A Randomized Trial of Interstitial Radiotherapy Boost for Newly Diagnosed Malignant Glioma: Brain Tumor Cooperative Group (BTCG) Trial 8701. Procedures Am Soc Clin Oncology 1994; Dallas TX; 174. Grishchuk D, Dimitriadis A, Sahgal A, et al.(2023) ISRS Technical Guidelines for Stereotactic Radiosurgery: Treatment of Small Brain Metastases (less than or equal to 1 cm in Diameter). Pract Radiat Oncol. 2023; 13(3): 183-194. PMID 36435388 Guleser UY, Sarici AM, Ucar D, et al(2022) Comparison of iodine-125 plaque brachytherapy and gamma knife stereotactic radiosurgery treatment outcomes for uveal melanoma patients Graefes Arch Clin Exp Ophthalmol Apr 2022; 260(4): 1337-1343 PMID 34735632 Hannan R, Christensen M, Hammers H, et al(2022) Phase II Trial of Stereotactic Ablative Radiation for Oligoprogressive Metastatic Kidney Cancer Eur Urol Oncol Apr 2022; 5(2): 216-224 PMID 34986993 Harrow S, Palma DA, Olson R, et al.(2022) Stereotactic Radiation for the Comprehensive Treatment of Oligometastases (SABR-COMET): Extended Long-Term Outcomes. Int J Radiat Oncol Biol Phys. Nov 15 2022; 114(4): 611-616. PMID 35643253 Hartgerink D, Bruynzeel A, Eekers D, et al(2021) A Dutch phase III randomized multicenter trial: whole brain radiotherapy versus stereotactic radiotherapy for 4-10 brain metastases Neurooncol Adv Jan-Dec 2021; 3(1): vdab021 PMID 33738451 Hartgerink D, Bruynzeel A, Eekers D, et al(2022) Quality of life among patients with 4 to 10 brain metastases after treatment with whole-brain radiotherapy vs stereotactic radiotherapy: a phase III, randomized, Dutch multicenter trial Ann Palliat Med Apr 2022; 11(4): 1197-1209 PMID 34806396 Hasegawa T, Kobayashi T, Kida Y.(2010) Tolerance of the optic apparatus in single-fraction irradiation using stereotactic radiosurgery: evaluation in 100 patients with craniopharyngioma. Neurosurgery 2010; 66(4):688-94; discussion 94-5. Hashizume C, Mori Y, Kobayashi T et al.(2010) Stereotactic radiotherapy using Novalis for craniopharyngioma adjacent to optic pathways. J Neuro-Oncol 2010; 98(2):239-47. Holy R, Piroth M, Pinkawa M et al.(2011) Stereotactic body radiation therapy (SBRT) for treatment of adrenal gland metastases from non-small cell lung cancer. Strahlentherapie und Onkologie : Organ der Deutschen Rontgengesellschaft ... [et al] 2011; 187(4):245-51. Ijsseldijk MA, Shoni M, Siegert C, et al.(2020) Oncologic Outcomes of Surgery Versus SBRT for Non-Small-Cell Lung Carcinoma: A Systematic Review and Meta-analysis. Clin Lung Cancer. May 07 2020. PMID 32912754 Ilyas A, Chen CJ, Abecassis IJ, et al.(2022) Stereotactic Radiosurgery for A Randomized Trial of Unruptured Brain Arteriovenous Malformations-Eligible Patients: A Meta-Analysis. Neurosurgery. Nov 01 2022; 91(5): 684-692. PMID 36001787 Intensity-modulated fractionated radiotherapy versus stereotactic body radiotherapy for prostate cancer (PACE-B): acute toxicity findings from an international, randomised, open-label, phase 3, non-inferiority trial.(2019) Brand DH, Tree AC, Ostler P et al, PACE Trial Investigators. Lancet Oncol. 2019;20(11):1531. Ito K, Sugita S, Nakajima Y, et al(2022) Phase 2 Clinical Trial of Separation Surgery Followed by Stereotactic Body Radiation Therapy for Metastatic Epidural Spinal Cord Compression Int J Radiat Oncol Biol Phys Jan 01 2022; 112(1): 106-113 PMID 3471525 Ivan ME, Sughrue ME, Clark AJ et al.(2011) A meta-analysis of tumor control rates and treatment-related morbidity for patients with glomus jugulare tumors. J Neurosurg 2011; 114(5):1299-305. Jacob R, Turley F, Redden DT, et al.(2015) Adjuvant stereotactic body radiotherapy following transarterial chemoembolization in patients with non-resectable hepatocellular carcinoma tumours of >/= 3 cm. HPB (Oxford). Feb 2015;17(2):140-149. PMID 25186290 Jeppesen SS, Schytte T, Jensen HR, et al.(2013) Stereotactic body radiation therapy versus conventional radiation therapy in patients with early stage non-small cell lung cancer: an updated retrospective study on local failure and survival rates. Acta Oncol. Oct 2013;52(7):1552-1558. PMID 23902274 Ji R, Ng KK, Chen W, et al(2022) Comparison of clinical outcome between stereotactic body radiotherapy and radiofrequency ablation for unresectable hepatocellular carcinoma Medicine (Baltimore) Jan 28 2022; 101(4): e28545 PMID 35089192 Jung J, Yoon SM, Kim SY, et al.(2013) Radiation-induced liver disease after stereotactic body radiotherapy for small hepatocellular carcinoma: clinical and dose-volumetric parameters. Radiat Oncol. 2013;8:249. PMID 24160910 Kano H, Kondziolka D, Flickinger JC et al.(2012) Stereotactic radiosurgery for arteriovenous malformations, Part 6: multistaged volumetric management of large arteriovenous malformations. Journal of neurosurgery 2012; 116(1):54-65. Katz AJ, Santoro M, Ashley R et al.(2010) Stereotactic body radiotherapy for organ-confined prostate cancer. BMC urology 2010; 10:1. Katz AJ, Santoro M, Diblasio F et al.(2013) Stereotactic body radiotherapy for localized prostate cancer: disease control and quality of life at 6 years. Radiat Oncol 2013; 8(1):118. Kihistrom L, Karisson B, Lindquist C.(1993) Gamma Knife Surgery for Cerebral Metastases: Implications for Survival Based on 16 Years Experience. Stereotactic Func Neurosurg 1993; 61(S1):45-50. Kim DW, Cho LC, Straka C, et al.(2014) Predictors of rectal tolerance observed in a dose-escalated phase 1-2 trial of stereotactic body radiation therapy for prostate cancer. Int J Radiat Oncol Biol Phys. Jul 1 2014;89(3):509-517. PMID 24929162 King CR, Collins S, Fuller D, et al.(2013) Health-related quality of life after stereotactic body radiation therapy for localized prostate cancer: results from a multi-institutional consortium of prospective trials. Int J Radiat Oncol Biol Phys. Dec 1 2013;87(5):939-945. PMID 24119836 Kishan AU, Dang A, Katz AJ, Mantz CA, Collins SP et al.(2019) Long-term Outcomes of Stereotactic Body Radiotherapy for Low-Risk and Intermediate-Risk Prostate Cancer. JAMA Netw Open. 2019;2(2):e188006 Koike Y, Hosoda H, Ishiwata Y, et al.(1994) Effect of Radiosurgery Using Leksell Gamma Unit on Metastatic Brain Tumor: Autopsy Case Report. Neurology Med Chir 1994; 34:534-537(Tokyo). Kondziolka D, Lunsford LD.(1992) Radiosurgery of Meningiomas. Neurosurg Clin N Am 1992; 3:219-230. Kondziolka D, Nathoo N, et al.(2003) Long-term results after radiosurgery for bening intracranial tumors. Neurosurgy 2003; 53:815-22. Kondziolka D, Ong JG, Lee JY, et al.(2008) Gamma Knife thalamotomy for essential tremor. J Neurosurg. Jan 2008;108(1):111-117. PMID 18173319 Kondziolka D, Patel A, Lunsford LD, et al.(1999) Stereotactic radiosurgery plus whole brain radiotherapy versus radiotherapy alone for patients with multiple brain metastases. Int J Radiat Oncol Biol Phys 1999; 45(2):427-34. Kooshkabadi A, Lunsford LD, Tonetti D, et al.(2013) Gamma Knife thalamotomy for tremor in the magnetic resonance imaging era. J Neurosurg. Apr 2013;118(4):713-718. PMID 23373801 Kotecha R, Sahgal A, Rubens M, et al.(2020) Stereotactic radiosurgery for non-functioning pituitary adenomas: meta-analysis and International Stereotactic Radiosurgery Society practice opinion. Neuro Oncol. Mar 05 2020; 22(3): 318-332. PMID 31790121 Le Salles AAF, Hariz M, Bajada CL, et al.(1993) Comparison Between Radiosurgery and Stereotactic Fractionated Radiation for the Treatment of Brain Metastases. Acta Neurochir 1993; Sup; 58:115-118. Lee CC, Kano H, Yang HC, et al.(2014) Initial Gamma Knife radiosurgery for nonfunctioning pituitary adenomas. J Neurosurg. Mar 2014;120(3):647-654. PMID 24405068 Lee CC, Trifiletti DM, Sahgal A, et al.(2018) Stereotactic Radiosurgery for Benign (World Health Organization Grade I) Cavernous Sinus Meningiomas-International Stereotactic Radiosurgery Society (ISRS) Practice Guideline: A Systematic Review. Neurosurgery. Dec 01 2018; 83(6): 1128-1142. PMID 29554317 Lee CC, Yang HC, Chen CJ, et al.(2014) Gamma Knife surgery for craniopharyngioma: report on a 20-year experience. J Neurosurg. Dec 2014;121 Suppl:167-178. PMID 25434950 Lee J, Shin IS, Yoon WS, et al.(2020) Comparisons between radiofrequency ablation and stereotactic body radiotherapy for liver malignancies: Meta-analyses and a systematic review. Radiother Oncol. Apr 2020; 145: 63-70. PMID 31923711 Lee MT, Kim JJ, Dinniwell R, et al.(2009) Phase I study of individualized stereotactic body radiotherapy of liver metastases. J Clinical Oncology 2009; 27:1585-1591. Leibel SA, Scott CB, Loeffler JS.(1994) Contemporary Approaches to the Treatment of Malignant Gliomas with Radiation Therapy. Semin Oncol 1994; 21:198-219. Levin VA, Gutin PH, Leibel S.(1993) Neoplasms of the Central Nervous System. Cancer:Principles and Practice Oncology; 4th Ed; JB Lippincott; Philadelphia; 1679-1737. Devita VT, Hellman S, Rosenbert SA (Ed's); 1993. Li C, Wang L, Wu Q, et al.(2020) A meta-analysis comparing stereotactic body radiotherapy vs conventional radiotherapy in inoperable stage I non-small cell lung cancer. Medicine (Baltimore). Aug 21 2020; 99(34): e21715. PMID 32846789 Lim SY, Hodaie M, Fallis M, et al.(2010) Gamma knife thalamotomy for disabling tremor: a blinded evaluation. Arch Neurol. May 2010;67(5):584-588. PMID 20457958 Liu Z, He S, Li L.(2020) Comparison of Surgical Resection and Stereotactic Radiosurgery in the Initial Treatment of Brain Metastasis. Stereotact Funct Neurosurg. Sep 08 2020: 1-12. PMID 32898850 Loeffler JS, Alexander E, Shea M, et al.(1992) Radiosurgery as Part of the Initial Management of Patients with Malignant Gliomas. J Clin Oncol 1992; 10:1379-1385. Loeffler JS, Shrieve DC, Alexander E.(1994) Radiosurgery for Glioblastoma Multiforme: the Importance of Selection Criteria. Int J Radiat Oncol Biol Phys 1994; 30:731-733. Londero F, Grossi W, Morelli A, et al.(2020) Surgery versus stereotactic radiotherapy for treatment of pulmonary metastases. A systematic review of literature. Future Sci OA. Apr 15 2020; 6(5): FSO471. PMID 32518686 Long Y, Liang Y, Li S, et al.(2021) Therapeutic outcome and related predictors of stereotactic body radiotherapy for small liver-confined HCC: a systematic review and meta-analysis of observational studies. Radiat Oncol. Apr 08 2021; 16(1): 68. PMID 33832536 Long-term results of lung metastasectomy: prognostic analyses based on 5206 cases. The International Registry of Lung Metastases. J Thorac Cardiovasc Surg 1997; 113(1):37-49. Lunsford LD.(1994) Contemporary Management of Meningiomas: Radiation Therapy as an Adjuvant and Radiosurgery as an Alternative to Surgical Removal. J NeuroSurg 1994; 80:187-190. Lutz S, Balboni T, Jones J, et al.(2017) Palliative radiation therapy for bone metastases: Update of an ASTRO Evidence-Based Guideline. Pract Radiat Oncol. Jan - Feb 2017;7(1):4-12. PMID 27663933 Magro E, Gentric JC, Darsaut TE, et al.(2017) Responses to ARUBA: a systematic review and critical analysis for the design of future arteriovenous malformation trials. J Neurosurg. Feb 2017;126(2):486-494. PMID 27128584 Mannina EM, Cardenes HR, Lasley FD, et al.(2017) Role of stereotactic body radiation therapy before orthotopic liver transplantation: retrospective evaluation of pathologic response and outcomes. Int J Radiat Oncol Biol Phys. Apr 01 2017;97(5):931-938. PMID 28333015 Marchetti M, Sahgal A, De Salles AAF, et al.(2020) Stereotactic Radiosurgery for Intracranial Noncavernous Sinus Benign Meningioma: International Stereotactic Radiosurgery Society Systematic Review, Meta-Analysis and Practice Guideline. Neurosurgery. Oct 15 2020; 87(5): 879-890. PMID 32463867 Martinez-Moreno NE, Sahgal A, De Salles A, et al.(2018) Stereotactic radiosurgery for tremor: systematic review. J Neurosurg. Feb 01 2018: 1-12. PMID 29473775 Masciopinto JE, Levin AB, Mehta MP, et al.(1995) Stereotactic Radiosurgery for Glioblastoma: A Final Report of 31 Patients. J NeuroSurg 1995; 82:530-549. Mathieu D, Kotecha R, Sahgal A, et al(2022) Stereotactic radiosurgery for secretory pituitary adenomas: systematic review and International Stereotactic Radiosurgery Society practice recommendations J Neurosurg Mar 01 2022; 136(3): 801-812 PMID 34479203 Matsuo T, Kamada K, Izumo T, et al.(2014) Linear accelerator-based radiosurgery alone for arteriovenous malformation: more than 12 years of observation. Int J Radiat Oncol Biol Phys. Jul 1 2014;89(3):576-583. PMID 24803036 Mazloom A, Hezel AF, Katz AW.(2014) Stereotactic body radiation therapy as a bridge to transplantation and for recurrent disease in the transplanted liver of a patient with hepatocellular carcinoma. Case Rep Oncol. Jan 2014;7(1):18-22. PMID 24575010 McGonigal A, Sahgal A, De Salles A, et al.(2017) Radiosurgery for epilepsy: Systematic review and International Stereotactic Radiosurgery Society (ISRS) practice guideline. Epilepsy Res. Nov 2017; 137: 123-131. PMID 28939289 Mehta MP, Masciopinto J, Rozenthal J, et al.(1994) Stereotactic Radiosurgery for Glioblastoma Multiform: Report of a Prospective Study Evaluating Prognostic Factors and Analyzing Long-term Survival Advantage. Int J Radiat Oncol Biol Phys 1994; 30:541-549. Meng MB, Cui YL, Lu Y et al.(2009) Transcatheter arterial chemoembolization in combination with radiotherapy for unresectable hepatocellular carcinoma: a systematic review and meta-analysis. Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology 2009; 92(2):184-94. Milano MT, Katz AW, Zhang H et al.(2012) Oligometastases treated with stereotactic body radiotherapy: long-term follow-up of prospective study. International journal of radiation oncology, biology, physics 2012; 83(3):878-86. Mohr JP, Parides MK, Stapf C, et al.(2014) Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. Lancet. Feb 15 2014;383(9917):614-621. PMID 24268105 Morgan SC, Hoffman K, Loblaw DA, Buyyounouski MK, Patton C, Barocas D, Bentzen S, Chang M, Efstathiou J, Greany P, Halvorsen P, Koontz BF, Lawton C, Leyrer CM, Lin D, Ray M, Sandler H.(2018) Hypofractionated Radiation Therapy for Localized Prostate Cancer: An ASTRO, ASCO, and AUA Evidence-Based Guideline. J Urol. 2018; Muller K, Naus N, Nowak PJ et al.(2012) Fractionated stereotactic radiotherapy for uveal melanoma, late clinical results. Radiother Oncol 2012; 102(2):219-24. Muzevic D, Legcevic J, Splavski B, et al.(2014) Stereotactic radiotherapy for vestibular schwannoma. Cochrane Database Syst Rev. Dec 16 2014(12):Cd009897. PMID 25511415 Myrehaug S, Sahgal A, Hayashi M, et al.(2017) Reirradiation spine stereotactic body radiation therapy for spinal metastases: systematic review. J Neurosurg Spine. Oct 2017; 27(4): 428-435. PMID 28708043 Napieralska A, Miszczyk L, Tukiendorf A, et al.(2014) The Results of Treatment of Prostate Cancer Bone Metastases after CyberKnife Radiosurgery. Ortop Traumatol Rehabil. Jul 3 2014;16(3):339- 349. PMID 25058109 National Comprehensive Cancer Network (NCCN).(2020) NCCN clinical practice guidelines in oncology. https://www.nccn.org/professionals/physician_gls (Accessed on October 14, 2020). National Comprehensive Cancer Network (NCCN).(2023) NCCN Clinical Practice Guidelines in Oncology. https://www.nccn.org/guidelines/category_1. Accessed May 23, 2023. Niranjan A, Lunsford LD.(2013) Stereotactic radiosurgery guideline for the management of patients with intracranial arteriovenous malformations. Prog Neurol Surg. 2013;27:130-140. PMID 23258517 Niranjan A, Raju SS, Kooshkabadi A, et al.(2017) Stereotactic radiosurgery for essential tremor: Retrospective analysis of a 19-year experience. Mov Disord. May 2017;32(5):769-777. PMID 28319282 Norihisa Y, Nagata Y, Takayama K et al.(2008) Stereotactic body radiotherapy for oligometastatic lung tumors. Int J Radiat Oncol Biol Phys 2008; 72(2):398-403. Ohye C, Higuchi Y, Shibazaki T, et al.(2012) Gamma knife thalamotomy for Parkinson disease and essential tremor: a prospective multicenter study. Neurosurgery. Mar 2012;70(3):526-535; discussion 535-526. PMID 21904267 Ong V, Bourcier AJ, Florence TJ, et al(2022) Stereotactic Radiosurgery for Glomus Jugulare Tumors: Systematic Review and Meta-Analysis World Neurosurg Jun 2022; 162: e49-e57 PMID 35189418 Osti MF, Carnevale A, Valeriani M, et al.(2013) Clinical outcomes of single dose stereotactic radiotherapy for lung metastases. Clin Lung Cancer. Nov 2013;14(6):699-703. PMID 23886798 Palma DA, Olson R, Harrow S, et al.(2019) Stereotactic ablative radiotherapy versus standard of care palliative treatment in patients with oligometastatic cancers (SABR-COMET): a randomised, phase 2, open-label trial. Lancet. May 18 2019; 393(10185): 2051-2058. PMID 30982687 Palma DA, Olson R, Harrow S, et al.(2020) Stereotactic Ablative Radiotherapy for the Comprehensive Treatment of Oligometastatic Cancers: Long-Term Results of the SABR-COMET Phase II Randomized Trial. J Clin Oncol. Sep 01 2020; 38(25): 2830-2838. PMID 32484754 Palta M, Godfrey D, Goodman KA, et al.(2019) Radiation Therapy for Pancreatic Cancer: Executive Summary of an ASTRO Clinical Practice Guideline. Pract Radiat Oncol. 2019; 9(5): 322-332. PMID 31474330 Parker T, Rigney G, Kallos J, et al.(2020) Gamma knife radiosurgery for uveal melanomas and metastases: a systematic review and meta-analysis. Lancet Oncol. Nov 2020; 21(11): 1526-1536. PMID 33152286 Patil CG, Pricola K, Garg SK, et al.(2010) Whole brain radiation therapy (WBRT) alone versus WBRT and radiosurgery for the treatment of brain metastases. Cochrane Database Syst Rev. Jun 16 2010; (6): CD006121. PMID 20556764 Patil CG, Pricola K, Sarmiento JM, et al.(2012) Whole brain radiation therapy (WBRT) alone versus WBRT and radiosurgery for the treatment of brain metastases. Cochrane Database Syst Rev. Sep 12 2012; (9): CD006121. PMID 22972090 Patil CG, Pricola K, Sarmiento JM, et al.(2017) Whole brain radiation therapy (WBRT) alone versus WBRT and radiosurgery for the treatment of brain metastases. Cochrane Database Syst Rev. Sep 25 2017; 9: CD006121. PMID 28945270 Paul L, Casasco A, Kusak ME, et al.(2014) Results for a Series of 697 AVMs Treated by Gamma Knife: Influence of Angiographic Features on the Obliteration Rate. Neurosurgery. Jul 18 2014. PMID 25050575 Persson O, Bartek J, Jr., Shalom NB, et al.(2017) Stereotactic radiosurgery vs. fractionated radiotherapy for tumor control in vestibular schwannoma patients: a systematic review. Acta Neurochir (Wien). Jun 2017;159(6):1013-1021. PMID 28409393 Petrovich Z, Yu C, et al.(2003) Gamma knife radiosurgery for pituitary adenoma: Early results. Neurosurgery 2003; 53:51-61. Phillips R, Shi WY, Deek M, et al.(2020) Outcomes of Observation vs Stereotactic Ablative Radiation for Oligometastatic Prostate Cancer: The ORIOLE Phase 2 Randomized Clinical Trial. JAMA Oncol. May 01 2020; 6(5): 650-659. PMID 32215577 Pollock BE, Driscoll CL, Foote RL, et al.(2006) Patient outcomes after vestibular schwannoma management: a prospective comparison of microsurgical resection and stereotactic radiosurgery. Neurosurgery. Jul 2006;59(1):77-85; discussion 77-85. PMID 16823303 Port JL, Parashar B, Osakwe N, et al.(2014) A Propensity-Matched Analysis of Wedge Resection and Stereotactic Body Radiotherapy for Early Stage Lung Cancer. Ann Thorac Surg. Jul 29 2014. PMID 25085557 Potts MB, Sheth SA, Louie J, et al.(2014) Stereotactic radiosurgery at a low marginal dose for the treatment of pediatric arteriovenous malformations: obliteration, complications, and functional outcomes. J Neurosurg Pediatr. Jul 2014;14(1):1-11. PMID 24766309 Raizer J.(2006) Radiosurgery and whole-brain radiation therapy for brain metastases: either or both as the optimal treatment. JAMA, 2006; 295:2535-6. Raldow AC, Chiang VL, Knisely JP, et al.(2013) Survival and intracranial control of patients with 5 or more brain metastases treated with gamma knife stereotactic radiosurgery. Am J Clin Oncol. Oct 2013;36(5):486-490. PMID 22706180 Ranck MC, Golden DW, Corbin KS, et al.(2013) Stereotactic body radiotherapy for the treatment of oligometastatic renal cell carcinoma. Am J Clin Oncol. Dec 2013;36(6):589-595. PMID 22868242 Rava P, Leonard K, Sioshansi S, et al.(2013) Survival among patients with 10 or more brain metastases treated with stereotactic radiosurgery. J Neurosurg. Aug 2013;119(2):457-462. PMID 23662828 Regis J, Bartolomei F, Rey M, et al.(2000) Gamma knife surgery for mesial temporal lobe epilepsy. J Neurosurg 2000; 93( sup 3):141-6. Reynolds MM, Arnett AL, Parney IF, et al.(2017) Gamma knife radiosurgery for the treatment of uveal melanoma and uveal metastases. Int J Retina Vitreous. Jun 2017;3:17. PMID 28560050 Roberts DG, Pouratian N.(2017) Stereotactic radiosurgery for the treatment of chronic intractable pain: a systematic review. Oper Neurosurg (Hagerstown). Oct 01 2017;13(5):543-551. PMID 28521018 Rusthoven KE, Kavanagh BD, Burri SH, et al.(2009) Multi-Institutional Phase I/II Trial of Stereotactic Body Radiation Therapy for Lung Metastases. J Clinical Oncology 2009; 27:1579-1584. Rusthoven KE, Kavanagh BD, Cardenes H et al.(2009) Multi-institutional phase I/II trial of stereotactic body radiation therapy for liver metastases. J Clin Oncol 2009; 27(10):1572-8. Sahgal A, Atenafu EG, Chao S, et al.(2013) Vertebral compression fracture after spine stereotactic body radiotherapy: a multi-institutional analysis with a focus on radiation dose and the spinal instability neoplastic score. J Clin Oncol. Sep 20 2013;31(27):3426-3431. PMID 23960179 Sahgal A, Myrehaug SD, Siva S, et al(2021) Stereotactic body radiotherapy versus conventional external beam radiotherapy in patients with painful spinal metastases: an open-label, multicentre, randomised, controlled, phase 2/3 trial Lancet Oncol Jul 2021; 22(7): 1023-1033 PMID 34126044 Sapisochin G, Barry A, Doherty M, et al.(2017) Stereotactic body radiotherapy vs. TACE or RFA as a bridge to transplant in patients with hepatocellular carcinoma. An intention-to-treat analysis. J Hepatol. Jul 2017;67(1):92-99. PMID 28257902 Sarici AM, Pazarli H.(2013) Gamma-knife-based stereotactic radiosurgery for medium- and large-sized posterior uveal melanoma. Ophthalmologie 2013; 251(1):285-94. Savardekar AR, Terrell D, Lele SJ, et al(2022) Primary Treatment of Small to Medium ( 3 cm) Sporadic Vestibular Schwannomas: A Systematic Review and Meta-Analysis on Hearing Preservation and Tumor Control Rates for Microsurgery versus Radiosurgery World Neurosurg Apr 2022; 160: 102-113e12 PMID 34838768 Schrottner O, Eder HG, Unger F, et al.(1998) Radiosurgery in lesional epilepsy: brain tumors. Stereotact Funct Neurosurg 1998; 70(sup 1):50-6. Scorsetti M, Alongi F, Filippi AR et al.(2012) Long-term local control achieved after hypofractionated stereotactic body radiotherapy for adrenal gland metastases: A retrospective analysis of 34 patients. Acta Oncol 2012; 51(5):618-23. Shanker MD, Moodaley P, Soon W, et al(2021) Stereotactic ablative radiotherapy for hepatocellular carcinoma: A systematic review and meta-analysis of local control, survival and toxicity outcomes J Med Imaging Radiat Oncol Dec 2021; 65(7): 956-968 PMID 34396706 Sharma H.(2014) Role of external beam radiation therapy in management of hepatocellular carcinoma. J Clin Exp Hepatol. Aug 2014;4(Suppl 3):S122-125. PMID 25755603 Sheehan JP, Starke RM, Mathieu D, et al.(2013) Gamma Knife radiosurgery for the management of nonfunctioning pituitary adenomas: a multicenter study. J Neurosurg. Aug 2013;119(2):446-456. PMID 23621595 Shrieve DC, Alexander E, Wen PY, et al.(1995) Comparison of Stereotactic Radiosurgery and Brachytherapy in the Treatment of Recurrent Glioblastoma Multiforme. Neurosurg 1995; 36:275-284. Singh R, Chen CJ, Didwania P, et al(2022) Stereotactic Radiosurgery for Dural Arteriovenous Fistulas: A Systematic Review and Meta-Analysis and International Stereotactic Radiosurgery Society Practice Guidelines Neurosurgery Jul 01 2022; 91(1): 43-58 PMID 35383682 Siva S, MacManus M, Ball D.(2010) Stereotactic radiotherapy for pulmonary oligometastases: a systematic review. J Thorac Oncol 2010; 5(7):1091-9. Solda F, Lodge M, Ashley S, et al.(2013) Stereotactic radiotherapy (SABR) for the treatment of primary non-small cell lung cancer; systematic review and comparison with a surgical cohort. Radiother Oncol. Oct 2013;109(1):1-7. PMID 24128806 Stanic S, Paulus R, Timmerman RD, et al.(2014) No clinically significant changes in pulmonary function following stereotactic body radiation therapy for early- stage peripheral non-small cell lung cancer: an analysis of RTOG 0236. Int J Radiat Oncol Biol Phys. Apr 01 2014;88(5):1092-1099. PMID 24661663 Su TS, Lu HZ, Cheng T, et al.(2016) Long-term survival analysis in combined transarterial embolization and stereotactic body radiation therapy versus stereotactic body radiation monotherapy for unresectable hepatocellular carcinoma >5 cm. BMC Cancer. Nov 03 2016;16(1):834. PMID 27809890 Taunk NK, Spratt DE, Bilsky M, et al.(2015) Spine radiosurgery in the management of renal cell carcinoma metastases. J Natl Compr Canc Netw. Jun 2015;13(6):801-809; quiz 809. PMID 26085394 Tian LJ, Zhuang HQ, Yuan ZY.(2013) A comparison between cyberknife and neurosurgery in solitary brain metastases from non-small cell lung cancer. Clin Neurol Neurosurg. Oct 2013;115(10):2009-2014. PMID 23850045 Timmerman R, Paulus R, Galvin J, et al.(2010) Stereotactic body radiation therapy for inoperable early stage lung cancer. Jama. Mar 17 2010;303(11):1070-1076. PMID 20233825 Tipton KN, Sullivan N, Bruening W, et al.(2011) Stereotactic Body Radiation Therapy. Technical Brief No. 6 (Prepared by ECRI Institute) AHRQ Publication No. 10(11)-EHC058-EF. Rockville, MD: Agency for Healthcare Research and Quality. May 2011. Available at www.effectivehealthcare.ahrq.gov/reports/final.cfm Tishler R, Loeffler JS, Lunsford LD, et al.(1993) Tolerance of Cranial Nerves of the Cavernous Sinus to Radiosurgery. Int J Radiat Oncol Biol Phys 1993; 27:215-221. Tonetti D, Kano H, Bowden G, et al.(2014) Hemorrhage during pregnancy in the latency interval after stereotactic radiosurgery for arteriovenous malformations. J Neurosurg. Dec 2014;121 Suppl:226-231. PMID 25434957 Tree AC, Khoo VS, Eeles RA et al.(2013) Stereotactic body radiotherapy for oligometastases. Lancet Oncol 2013; 14(1):e28-37. Tsao MN, Rades D, Wirth A, et al.(2012) Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es): An American Society for Radiation Oncology evidence-based guideline. Pract Radiat Oncol. Jul 2012;2(3):210-225. PMID 24175001 Tsao MN, Ven LI', Cheung P, et al.(2020) Stereotactic Body Radiation Therapy for Extracranial Oligometastatic Non-small-cell Lung Cancer: A Systematic Review. Clin Lung Cancer. Mar 2020; 21(2): 95-105.e1. PMID 31959533 Tuleasca C, Regis J, Sahgal A, et al.(2018) Stereotactic radiosurgery for trigeminal neuralgia: a systematic review. J Neurosurg. Apr 27 2018; 130(3): 733-757. PMID 29701555 Valentino V, Schinaia G, Raimondi AJ.(1993) The Results of Radiosurgical Management of 72 Middle Fossa Meningiomas. Acta Neurochir 1993; 122:60-70. Vargas CE, Schmidt MQ, Niska JR, et al.(2018) Initial toxicity, quality-of-life outcomes, and dosimetric impact in a randomized phase 3 trial of hypofractionated versus standard fractionated proton therapy for low-risk prostate cancer. Adv Radiat Oncol. 2018; 3(3): 322-330. PMID 30202801 Varlotto J, Fakiris A, Flickinger J, et al.(2013) Matched-pair and propensity score comparisons of outcomes of patients with clinical stage I non-small cell lung cancer treated with resection or stereotactic radiosurgery. Cancer. Aug 1 2013;119(15):2683-2691. PMID 23605504 Verma J, Jonasch E, Allen PK, et al.(2013) The impact of tyrosine kinase inhibitors on the multimodality treatment of brain metastases from renal cell carcinoma. Am J Clin Oncol. Dec 2013;36(6):620-624. PMID 22892430 Videtic GMM, Donington J, Giuliani M, et al.(2017) Stereotactic body radiation therapy for early-stage non-small cell lung cancer: Executive Summary of an ASTRO Evidence-Based Guideline. Pract Radiat Oncol. Sep - Oct 2017;7(5):295-301. PMID 28596092 Vogelbaum MA, Brown PD, Messersmith H, et al(2022) Treatment for Brain Metastases: ASCO-SNO-ASTRO Guideline J Clin Oncol Feb 10 2022; 40(5): 492-516 PMID 34932393 Wackernagel W, Holl E, Tarmann L, et al.(2014) Local tumour control and eye preservation after gamma-knife radiosurgery of choroidal melanomas. Br J Ophthalmol. Feb 2014;98(2):218-223. PMID 24169651 Wahl DR, Stenmark MH, Tao Y, et al.(2016) Outcomes after stereotactic body radiotherapy or radiofrequency ablation for hepatocellular carcinoma. J Clin Oncol. Feb 10 2016;34(5):452-459. PMID 26628466 Wakefield DV, Venable GT, VanderWalde NA, et al.(2017) Comparative neurologic outcomes of salvage and definitive Gamma Knife radiosurgery for glomus jugulare: a 20-year experience. J Neurol Surg B Skull Base. Jun 2017;78(3):251-255. PMID 28593112 Wang PM, Chung NN, Hsu WC, et al.(2015) Stereotactic body radiation therapy in hepatocellular carcinoma: Optimal treatment strategies based on liver segmentation and functional hepatic reserve. Rep Pract Oncol Radiother. Nov-Dec 2015;20(6):417-424. PMID 26696781 Weltman E, Salvajoli JV, Brandt RA, et al.(2000) Radiosurgery for brain metastases: a score index for predicting prognosis. Int J Radiat Oncol Biol Phys 2000; 46(5):1155-61. Whang CJ, Kwon Y.(1996) Long-term follow-up of stereotactic Gamma Knife radiosurgery in epilepsy. Stereotact Funct Neurosurg 1996; 66(sup 1):349-56. Widmark A, Gunnlaugsson A, Beckman L, Thellenberg-Karlsson C, Hoyer M, Lagerlund M, Kindblom J, Ginman C, Johansson B, Björnlinger K, Seke M, Agrup M, Fransson P, Tavelin B, Norman D, Zackrisson B, Anderson H, Kjellén E, Franzén L, Nilsson P.(2019) Ultra-hypofractionated versus conventionally fractionated radiotherapy for prostate cancer: 5-year outcomes of the HYPO-RT-PC randomised, non-inferiority, phase 3 trial. Lancet. 2019;394(10196):385. Williams BJ, Xu Z, Salvetti DJ, et al.(2013) Gamma Knife surgery for large vestibular schwannomas: a single-center retrospective case-matched comparison assessing the effect of lesion size. J Neurosurg. Aug 2013;119(2):463-471. PMID 23706053 Witjas T, Carron R, Krack P, et al.(2015) A prospective single-blind study of Gamma Knife thalamotomy for tremor. Neurology. Nov 03 2015;85(18):1562-1568. PMID 26446066 Yamamoto M, Serizawa T, Shuto T, et al.(2014) Stereotactic radiosurgery for patients with multiple brain metastases (JLGK0901): a multi-institutional prospective observational study. Lancet Oncol. Apr 2014;15(4):387-395. PMID 24621620 Yamamoto T, Kadoya N, Takeda K, et al.(2016) Renal atrophy after stereotactic body radiotherapy for renal cell carcinoma. Radiat Oncol. May 26 2016;11:72. PMID 27229710 Yan M, Moideen N, Bratti VF, et al.(2020) Stereotactic body radiotherapy (SBRT) in metachronous oligometastatic prostate cancer: a systematic review and meta-analysis on the current prospective evidence. Br J Radiol. Dec 01 2020; 93(1116): 20200496. PMID 32822547 Yomo S, Hayashi M.(2014) Upfront stereotactic radiosurgery in patients with brain metastases from small cell lung cancer: retrospective analysis of 41 patients. Radiat Oncol. 2014;9(1):152. PMID 25005424 Yoon SM, Lim YS, Park MJ, et al.(2013) Stereotactic body radiation therapy as an alternative treatment for small hepatocellular carcinoma. PLoS One. 2013;8(11):e79854. PMID 24255719 Young RF, Jacques S, Mark R, et al.(2000) Gamma knife thalamotomy for treatment of tremor: longterm results. J Neurosurg. Dec 2000;93 Suppl 3:128-135. PMID 11143229 Yu C, Chen JC, Apuzzo ML, et al.(2002) Metastatic melanoma to the brain: prognostic factors after gamma knife radiosurgery. Int J Radiat Oncol Biol Phys 2002; 52(5):1277-87. Yu C, Chen JC, Apuzzo ML, et al.(2002) Metastatic melanoma to the brain: prognostic factors after gamma knife radiosurgery. Int J Radiat Oncol Biol Phys. Apr 1 2002;52(5):1277-1287. PMID 11955740 Yu JB, Cramer LD, Herrin J, et al.(2014) Stereotactic body radiation therapy versus intensity-modulated radiation therapy for prostate cancer: comparison of toxicity. J Clin Oncol. Apr 20 2014;32(12):1195-1201. PMID 24616315 Yuan ZY, Meng MB, Liu CL, et al.(2014) Stereotactic body radiation therapy using the CyberKnife((R)) system for patients with liver metastases. Onco Targets Ther. Jun 2014;7:915-923. PMID 24959080 Zakrzewska JM, Akram H.(2011) Neurosurgical interventions for the treatment of classical trigeminal neuralgia. Cochrane Database Syst Rev. Sep 07 2011(9):Cd007312. PMID 21901707 Zehetmayer M.(2012) Stereotactic photon beam irradiation of uveal melanoma. Developments in ophthalmology 2012; 49:58-65. Zhang R, Kang J, Ren S, et al(2022) Comparison of stereotactic body radiotherapy and radiofrequency ablation for early-stage non-small cell lung cancer: a systematic review and meta-analysis Ann Transl Med Jan 2022; 10(2): 104 PMID 35282118 Zheng X, Schipper M, Kidwell K, et al.(2014) Survival Outcome After Stereotactic Body Radiation Therapy and Surgery for Stage I Non-Small Cell Lung Cancer: A Meta-Analysis. Int J Radiat Oncol Biol Phys. Jul 19 2014. PMID 25052562 Zhong J, Patel K, Switchenko J, et al.(2017) Outcomes for patients with locally advanced pancreatic adenocarcinoma treated with stereotactic body radiation therapy versus conventionally fractionated radiation. Cancer. Sep 15 2017;123(18):3486-3493. PMID 28493288 Zhong NB, Lv GM, Chen ZH.(2014) Stereotactic body radiotherapy combined with transarterial chemoembolization for huge (>/=10 cm) hepatocellular carcinomas: A clinical study. Mol Clin Oncol. Sep 2014;2(5):839-844. PMID 25054055 |
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