Two-Session Radiosurgery for Large Primary Tumors Affecting the Brain

Introduction Surgery is an option for patients with large, symptomatic primary tumors affecting the brain. However, surgery might not be suitable for all tumors, especially those located in sensitive areas such as the pineal region and the hypothalamus. Single-session stereotactic radiosurgery (SRS) might not provide an adequate dose for long-term local control due to the initial tumor volume and the involvement of radiation sensitive organs at risk (OARs). Two-session radiosurgery has been described as a feasible strategy for dose escalation in large secondary brain tumors. This report describes a series of patients treated upfront with two-session radiosurgery for primary tumors affecting the brain. Materials and methods From May 2017 to January 2020, eight patients with primary tumors affecting the brain were treated with two-session radiosurgery due to either an initial large tumor volume or tumor localization and the involvement of OARs. The response was assessed by imaging and clinical evaluations. Results A total of eight patients were treated, nine tumors were treated with two-session radiosurgery, four patients had tumors in the pineal region (50%), and the rest were in the hypothalamic region (25%) or elsewhere. The mean tumor volume for the first SRS session was 15 mL (range 5.2 to 51.6 mL), the mean prescription dose was 13 Gy, and the timespan between both sessions was 30 days (range, 30 to 42 days). During the second session, tumor volume was reduced to 73.6% (range, -20% to 98.7%) of the original dimension, mean tumor volume was 5 mL (range, 0.1 to 17.8 ml), mean prescription dose for the second session was 16.2 Gy estimated by time, dose, and fractionation and by bioequivalent dose under alpha-beta values often to be equivalent to a single dose of 15.8 Gy. Doses to the OARs for the optic pathway were equivalent to a single maximum dose of 9.75 Gy (range, 7.12 to 10.92), and to the brainstem, the equivalent was a maximum dose of 12.3 Gy (range, 5.6 to 15.07). At last follow-up, at a mean of 336.5 days (range, 65 to 962 days), seven patients were alive, five tumors had a partial response (PR), and three had stable disease in accordance to Response Evaluation Criteria in Solid Tumors (RECIST) criteria. One patient died 435 days after treatment, the Karnofsky Performance Status (KPS) was 90 at the first session, 90 at the second session, and was maintained at last follow-up. No adverse radiation effects were reported. Conclusions Two-stage SRS proved to be a safe method to escalate dose in proportionately large volume primary brain tumors whose histology is expected to have a quick biological response to radiation. Longer follow-up is needed to determine the long-term effectiveness by tumor subtypes of two-stage SRS in the same manner as it has been proven in single session SRS series in smaller tumor volumes.