Stereotactic Laser Ablation (SLA) Followed by Consolidation Stereotactic Radiosurgery (cSRS) as Treatment for Brain Metastasis that Recurred Locally After Initial Radiosurgery (BMRS): A Multi-Institutional Experience

Stereotactic Laser Ablation (SLA) Followed by Consolidation Stereotactic Radiosurgery (cSRS) as Treatment for Brain Metastasis that Recurred Locally After Initial Radiosurgery (BMRS): A Multi-Institutional Experience | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Stereotactic Laser Ablation (SLA) Followed by Consolidation Stereotactic Radiosurgery (cSRS) as Treatment for Brain Metastasis that Recurred Locally After Initial Radiosurgery (BMRS): A Multi-Institutional Experience Isabela Peña Pino, Jun Ma, Yusuke Hori, Elena Fomchenko, Kathryn Dusenbery, and 12 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-794328/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Introduction : The optimal treatment paradigm for brain metastasis that recurs locally after initial radiosurgery (BMRS) remains an area of active investigation. Here, we report outcomes for patients with BMRS treated with stereotactic laser ablation (SLA, also known as laser interstitial thermal therapy, LITT)followed by consolidation radiosurgery (cSRS). Methods : Clinical outcome of 20 patients with 21histologically confirmed BMRS treated with SLA followed by consolidation SRS and >6 months follow-up were collected retrospectively across three participating institutions. Results : Consolidation SRS (5 Gy x 5 or 6 Gy x 5) wascarried out 16-73 days (median of 26 days) post-SLA of BMRS. There were no new neurological deficits after SLA/cSRS. While 3/21 (14.3%) patients suffered temporary Karnofsky Performance Score (KPS) decline after SLA, no KPS declines was observed after cSRS. There were no 30-day mortalities or wound complications. Two patients required re-admission within 30 days of cSRS (severe headache that resolved with steroid therapy (n=1) and new onset seizure (n=1)). With a median follow-up of 228 days (range: 178-1367 days), the local control rate at 6 and 12 months (LC 6 , LC 12 ) was 100%. All showed diminished FLAIR volume surrounding the SLA/cSRS treated BMRS at the six-month follow-up; none of the patients required steroid for symptoms attributable to these BMRS. These results compare favorably to the available literature for repeat SRS or SLA-only treatment of BMRS. Conclusions : This multi-institutional experience supports further investigations of SLA/cSRS as a treatment strategyfor BMRS. Neurology Oncology Brain metastasis (BM) Stereotactic laser ablation (SLA) laser interstitial thermal therapy (LITT) stereotactic radiosurgery (SRS) Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction In independent randomized clinical trials, ~30% of BM recur locally after radiosurgery twelve months after treatment [1] . The local recurrence rate is higher for BM intrinsically resistant to radiation [2, 3] or those with up-regulated DNA repair capacity [4–6] . There is currently no consensus on the optimal treatment strategy for brain metastasis that recur after radiosurgery (BMRS). Repeat radiosurgery to BMRS is often employed in this context. However, such treatments are associated with an increased risk for neurologic decline secondary to adverse radiation effects, including radiation necrosis [7, 8] . These repeat radiation-associated deleterious effects can compromise the patient’s quality of life, delay systemic therapy, or necessitate surgical interventions [8, 9] . Moreover, up to 30% of repeat radiosurgery fail to achieve local control of BMRS [10] . Stereotactic laser ablation (SLA, also known as laser interstitial thermal therapy (LITT)) refers to a procedure whereby a fiberoptic laser probe is stereotactically inserted into a target abnormality in the brain or spine [11] . Activation of the probe induces hyperthermia within the target tissue, causing coagulative necrosis [11] . While SLA has been employed as a treatment for newly diagnosed BM, the clinical outcomes have been disappointing, with 30-50% local failure within twelve months of treatment [12–15] . Despite these results, there are reasons to consider SLA in combination with repeat radiosurgery as a treatment strategy for BMRS. First, there is sound laboratory science [16] , pre-clinical [17] , and clinical data [18–20] suggesting synergy in the anti-tumoral effects of hyperthermia and radiation. This synergy warrant consideration given the radiation resistant nature of BMRS. Second, SLA is a highly effective treatment for radiosurgery associated adverse radiation effects [14, 21, 22] . The available literature suggests that SLA inactivates immune cells and/or denatures inflammatory cytokines that mediate radiation-induced injuries [23] . Thus, the addition of SLA to repeat SRS can potentially mitigate risk of subsequent adverse radiation effects. In this context, we previously reported results from four BMRS patients treated with SLA followed by cSRS in 2016 [13] . Here, we report a larger multi-institutional experience examining the efficacy and safety profile of this treatment strategy for patients with > 6 months follow-up. Methods Patient population and data collection This study was a multi-institutional, retrospective case series of patients who underwent SLA/cSRS between 2012 and 2020 for needle biopsy-confirmed brain metastasis recurrence after initial SRS treatment. Each of the participating institutions holds an approved IRB for this retrospective review. To characterize longer-term effects of SLA/cSRS, we included only patients who had 6 months follow-up data. Demographic and clinical data collected from the electronic record system included: sex, age at BMRS presentation, primary tumor subtype, tumor location, tumor volume, prior whole brain radiation therapy (WBRT), 30-day readmission, and SLA/cSRS associated morbidity (including radiation induced adverse effects). Baseline and post-SLA/cSRSKarnofsky Performance Status (KPS) and steroid use were collected for all patients at time of BMRS diagnosis, one day post-SLA, one monthpost-cSRS, and at subsequent follow-up visits. As per standard of care, patients were seen by the neurosurgeon ~ 2 weeks after SLA. Patients were seen by the radiation oncologist one month after cSRS and every 2-3 months thereafter. Follow-up duration was calculated from the time of cSRS.Overall Survival was calculated from the time of initial cancer diagnosis. MRI analysis All patients underwent surveillance MRI every 2-3 months unless imaging or clinical findings warranted shorter interval follow-up. MRIs from each site are reviewed by two independent assessors. MRIs were obtained before and after treatment and imported into the Brainlab (BrainlabAG,Munich, Germany)iPlan Cranial 3.0 software or 3D Slicer ( www.slicer.org ) or image J ( https://imagej.nih.gov/ij/ ) to determine maximal diameter and volume. The volume of contrast enhancing (CE) and FLAIR volumes surrounding the SLA/cSRS treated lesion were recorded immediately post-SLA and for each imaging follow-up. Local control (LC) was defined using modified RANO-BM criteria [24] , as described below. Since the SLA ablated region often show expansion of contrast enhancement immediately post-procedure that resolves in the subsequent one to three months [25] , we define local failure as persistent increase of > 20% in the size of contrast enhancement (based on RANO-BM) relative to the time of BMRS presentation, on two sequential MRIs that were greater than three months apart (similar to immunotherapy RANO [26] ). Lesions demonstrating such local failure were surgically excised for definitive tissue diagnosis. SLA and consolidation SRS BMRS patients considered for SLA/cSRS were reviewed at a multi-disciplinary board consisting of representatives from neuro-oncology, neurosurgery, radiation oncology, neuroradiology, and neuropathology. Informed consents were obtained by neurosurgery and radiation oncology. The SLA procedures were performed as previously described [13] . For lesions treated with the NeuroBlate system (Monteris Medical Inc., Plymouth, MN, USA), extent of ablation was assessed based on CE region covered by blue contour line (equivalent to of tissue heating to 43 o C for > 10 minutes) [27] . For lesions treated with the Visualase system (Medtronics Inc., Minneapolis, MN), extent of ablation was assessed based on CE region covered by orange pixel (equivalent to tissue injury achieved at 60 o C). Consolidation SRS was carried out approximately one to two months after the SLA and delivered through five consecutive fractions of 5 Gy or 6 Gy. SRS treatment was performed using either the Leksell Gamma Knife Icon (Elekta Instrument AB, Stockholm, Sweden) or the TrueBeam linear accelerator (Varian Medical Systems, Palo Alto, California). The planned target volume (PTV) was defined by the entirety of the ablated lesion, including, regions of contrast enhancement ( Figure 1 ). For Icon-treated patients, PTV was prescribed to the 50% isodose. For the TrueBeam treated patients, PTV was prescribed to the 90% isodose. Literature search and statistical analysis The literature search was performed in June 2021, reviewed by the first author (IP) and senior author (CCC). For assessment of the published literature for SLA as treatment for BMRS, we repeated a search strategy that we had previously implemented in 2018 [13] . In this search, we identified two publications bearing information on the local control of BMRS after SLA. For assessment of the published literature for hypo-fractionated repeat SRS as treatment for BMRS, we repeated a published strategy that was implemented in 2019 by Loi et al [28] . We identified four publications bearing pertinent local control and adverse radiation effect information following repeat, hypo-fractionated radiosurgery of BMRS. GraphPad Prism Version 9 was used for all statistical analyses (GraphPad Software, San Diego, California). Categorical and continuous data are described as frequency (percentage) and median (interquartile range), respectively. Fisher’s exact test and the Mann-Whitney U-test were used for the univariate analyses of categorical and continuous data, respectively. Results Study population The study cohort consists of six male and thirteen female patients. The median age of the cohort was 64 years old (range: 34-74). The histology of the BMs treated included: lung (n=6), breast (n=5), gastrointestinal (n=3), melanoma (n=2), laryngeal (n=1), urothelial (n=1), ovarian (n=1), and undifferentiated (n=1). The medianCE tumor volume at the time of BMRS presentation was 5.6 cm 3 (range: 3.1-34.2 cm 3 ). All lesions were deemed difficult to access surgically by the treating neurosurgeon and underwent stereotactic needle biopsies, with pathology confirming BMRS. All lesions received 18-21 Gy of single fraction SRS at the time of initial diagnosis. The locations of the lesions as well as other demographic and tumor characteristics are shown in Table 1 . Except for patient 11, who was treated with WBRT two years prior to the initial SRS, none of the patients received prior WBRT. Patient 4 underwent two separate SLA/cSRS for lesions located in the frontal and parietal lobe, identified approximately six months apart. All other patients underwent a single SLA/cSRS. All patients were treated with corticosteroid following the BMRS diagnosis and prior to SLA. All patients underwent subsequent systemic therapy. SLA/cSRS and post-operative course The volume of BMRS CE ablated was as defined in Methods. Seventy-three to 100 % of the BMRS CE volume was ablated at the time of SLA ( Table 2 ). There were no new neurologic deficits immediately post-SLA or at the one-month follow-up. Consistent with previously published SLA series [14, 29] , the KPS of 80% (16/20) of the patients remain unchanged after SLA. Three of 20 (15%) suffered a temporary decline in KPS post-SLA, while 1/20 (5%) showed an improvement in KPS. All patients were discharged home within two days of SLA. There was no operative morbidity or mortality attributable to the SLA. Consolidation SRSwas performed one to two months after SLA and was performed as an out-patient procedure. The median time from SLA to cSRS was 26 days (range 16-73 days). The median BMRS CE volume for this series was 5.6 cm 3 . cSRS was targeted the post-ablative region, including the rim of contrast enhancement ( Figure 1 ). Eighteen of 20 (90%) of the patients were treated with a 5 Gy x 5 consecutive day regimen, and 2 patients were treated with a 6 Gy x 5 consecutive day regimen. By the time of cSRS, the three patients who suffered a KPS decline after SLA had recovered to their baseline KPS. All KPS remained stable at one-month post-cSRS. There were two 30-day post-SLA readmissions. Patient 7 presented with an incapacitating headache in the context of corticosteroid dose. The headache resolved after a temporary re-escalation of corticosteroid treatment. Patient 11 presented with a new-onset seizure and was placed on levetiracetam and a short course of corticosteroid. Of note, patient 11 is the only patient in this series who received WBRT prior to initial SRS. Head CT’s for both patients were without evidence of tumor hemorrhage but showed increased per-BMRS hypodensity. Both patients were discharged by hospital day 2. Of note, both admitted patients harbored BMRS that is larger than the median volume of the tumor treated in this series. The median BMRS CE volume for this series was 5.6 cm 3 ; the BMRS CE volumes for patients 7 and 11 were 35 cm 3 and 25.7 cm 3 , respectively. Imaging and clinical follow-up Follow-up duration and local control was calculated from the time of cSRS.The median follow-up for this cohort is 228 days (range: 183-1367 days). There were two treatment failures that occurred 1367 and 1161 days after SLA/cSRS (patients 13 and 14, Figure 2A ). Overall survival was calculated from the time of the cancer diagnosis. The median survival for this study cohort was 378 days ( Figure 2B ).Six months follow-up was available for all patients ( Table 3 ). At six months, the CE volumes for all SLA/cSRS treated lesions were decreased relative to the time of SLA. Similarly, the peri-CE FLAIR volumes for all treated lesionsdecreased relative to the initial BMRS presentation. Six months after SLA/cSRS, five out of 20 (25%) of the patients continued to be treated with corticosteroid. Based on both clinical documentation and surveillance MR imaging, the corticosteroid was used to treat symptoms related to other BM and unrelated to the SLA/cSRS treated BMRS, Twelve-month follow-up was available for five patients. Local control at twelve months (LC 12 ) was 100%, and the peri-CE FLAIR volumes remained decreased for the treated lesions relative to the time of SLA. None of the patients required corticosteroid treatment. Two illustrative cases are shown in Figures 3 and 4 . Figure 3 shows the evolution of CE and FLAIR after SLA/cSRS in the longest surviving patient (patient 8) whose BMRS remain controlled 19 months after SLA/cSRS. Figure 4 shows the evolution of CE and FLAIR after SLA/cSRS in a patient (patient 14) whose BMRS recurred 1161 days(~39 months) after SLA/cSRS. Literature of efficacy of repeat radiosurgery and stereotactic laser ablation (SLA) We wishto compare our case series to the published literature for salvage monotherapy using either SLA or repeat SRS for BMRS. The literature search for SLA treated BMRS (see Methods for the search algorithm) yielded one study that reported a local control of 61% at 4.6 months [13] . Broadening our search to include case series that include a mixture of pathology confirmed BMRS, newly diagnosed BMRS, and radiation necrosis, we identified two additional studies. The study by Ahluwalia et al. consisted of 22 pathology-confirmed BMRS and 22 radiation necrosis. Only three-month local control was reported (LC 3 ), and the reported LC 3 was 37% [14]. The second study by Bastos et al. consisted of 46 BMRS and 5 newly diagnosed BM. The reported LC 12 was 69.6% for this series [15] (Table 4A). Since our cSRSused a hypo-fractionated regimen, we focused our literature search to identify articles that studied the efficacy and safety of hypo-fractionated repeat SRS as a treatment for BMRS. We identified four such articles (Table 4B) [10, 30–32] . The reported local control at 12 months ranged 70-83%, with 13-19% of the patients suffering from symptomatic adverse radiation effects after repeat radiation. The LC 12 of 100% and 0% adverse radiation effects at 6 and 12 months after SLA/cSRS treatment of BMRS in our series compares favorably to these reported results. Discussion Our literature search suggests that the treatment of BMRS remains an understudied area in neuro-oncology. The overall poor survival of BM patients [33] likely contributes to this limited literature. Many BM patients die before developing recurrence. However, as newer classes of systemic therapies emerge and improve cancer survival, there will be a greater need for meaningful therapeutic interventions in the treatment of BMRS [34] . Here, we retrospectively analyzed a multi-institutional experience that employed SLA/cSRS as a treatment strategy for BMRS. This study builds on and expands on the clinical outcome of the four patients reported in our 2016 study [13] . By expanding the number of patients treated as well as lengthening the follow-up duration (to > 6 months), we provide data to support the safety profile and durable efficacy of SLA/cSRS as treatment for BMRS. Our current study suggests that the procedural safety profile of SLA/cSRS is comparable to that reported for SLA alone [13, 14, 35] . Because of the limited BMRS literature, we were unable to perform a meaningful, quantitative comparison between the results of this study to the available literature. Qualitatively, the LC 6 and LC 12 of 100% after SLA/cSRS for tissue confirmed BMRS in our series compares favorably to the reported LC 12 of 69.6% [15] for SLA alone. Of note, this SLA study included a mixed population of BMRS and newly diagnosed BM, with the latter presumably more radiation sensitive than the former. The local control of BMRS by SLA/cSRS also compares favorably to the 70-83% reported for repeat hypo-fractionated SRS. These results should be interpreted with the following consideration. While it is unlikely that any practitioner would purposely treat non-recurrent BM with repeat radiosurgery, the imaging methods available for assessing recurrent BM versus adverse radiation effects following radiosurgery remain imperfect [36] . As such, it is possible that a subset of the lesions thought to be BMRS on imaging may represent post-radiosurgery radiation effects. If so, the published study of BMRS without tissue diagnosis reports local control rates that may be artificially inflated [37] . In this context, it is notable that all BMRS in this series were confirmed by tissue. Another advantage of the SLA/cSRS treatment paradigm is highlighted by the absence of adverse radiation effects in our series compared to the13-19% reported withrepeat radiosurgery of BMRS. The neurologic sequelae of these adverse effects compromise the patient’s quality of life, requiring corticosteroid therapy, surgical therapy, or both. Since innate anti-tumoral responses play a key role in the efficacy of nearly all anti-cancer therapies, immune suppression secondary to corticosteroid administration may compromise the efficacy of systemic therapies [38] . Moreover, the advent of immunotherapy and targeted therapy has increased the risk for SRS-associated adverse radiation effects [39, 40] . As many as one in five melanoma BM patients treated with nivolumab and ipilimumab suffers adverse radiation effects after SRS, requiring cessation of systemic therapy [40] . Minimizing the risk of such cessation has the potential to improve therapeutic efficacy of systemic therapy. In this context, the absence of adverse radiation effects in our SLA/cSRS series despite repeat radiosurgery to the same lesion suggests that SLA may minimize the risk of adverse radiation effects,rendering the treatment strategy attractive. The imaging findings after SLA-cSRS are complex and worth noting. MRIs performed immediately post-SLA typically show an expansion in CE volume, accompanied by an enlargement of the surrounding FLAIR [27, 35] . While many SLA-treated lesions show egg-shell contrast enhancement ( Figures 3 and 4 ), others exhibit more heterogeneous enhancement patterns [12, 13, 41] . These SLA-associated MR changes typically resolve one to three months post-SLA [12, 13, 35, 41] . As such, assessment of MR at any single time point after SLA, such as that described by RANO-BM [42] , is inadequate for assessing tumor control. In this context, we modified the RANO-BM criteria to include the sequential surveillance MRIs, similar to that proposed for immunotherapy RANO (iRANO) [26] . We considered local failure only if the > 20% increase in CE volume remained persistent on MRIsscanned three months apart. The pilot data presented in our series support the utility of this proposed modification. Of the two cases (patient 13 and 14) that showed tumor progression at later time points based on the above proposed criteria, both underwent surgical resection, with specimens confirming tumor progression. An important consideration in patient selection for SLA involves the volume of the BMRS. Post-SLA edema is a well-documented phenomenon that can lead to morbidities and mortalities [13, 35] . In this context, the larger lesions treated in this series involved patients with either cerebral atrophy or who had undergone previous surgical resections. The atrophy or resection reduce cerebral volume to increase capacity for tolerating post-SLA edema. Despite the cautions exercised in patient selection, two of the patients (patient 7 and 11) with larger BMRS suffered 30-day readmission after SLA/cSRS for symptoms attributable to treated BMRS. Patient 11’s prior history of WBRT further suggest that the cumulative radiation dose may influence cerebral compliance and tolerance of post-SLA edema. As such, judicious consideration in patient selection and close follow-up of SLA/cSRS treated patients is warranted, especially for patients with larger tumor volumes or patients who had undergone multiple rounds of prior RT/SRS. As a retrospective analysis, our conclusions are subject to the influences of all forms of biases inherent within this study design [27] . Moreover, all BMRS presented in this series underwent SLA that achieved >70% ablation of the contrast enhancing tumor volume. As such, the results reported here may not be applicable if such extent of ablation was not achieved. Ultimately, a randomized control trial (RCT) will be needed to validate the results reported here. If the pilot safety and efficacy profiles reported here are recapitulated in an RCT, the results can contribute to a new standard of care for BMRS patients. While this case series focused exclusively on patients with recurrent BM, the approach should be applicable to other clinical contexts, including the treatment of BM with a high probability of SRS failure, such as larger volume melanoma BM in the upfront setting. Conclusion This multi-institutional experience provides pilot safety and efficacy data for hypo-fractionated SRS within two months of SLA treatment of BMRS and support continued investigation of this treatment strategy. The results described here informs the design of future randomized clinical trials. Declarations Funding: No funding was provided for this study. Conflicts of interest: The authors do not have any conflicts of interest to report Availability of data: Data will be made available upon request as deemed appropriate by the corresponding author Code availability: N/A Authors’ contributions: JM, YH, EF, KD, MR, CW, JY, ES, MG, PF, EDM, NF, GHB, VC and AM collected data. IPP drafted the manuscript. CCC conceived the study, performed procedures reported, drafted the manuscript. All authors edited the final draft of the manuscript and provided critical review. Ethics approval: This study was approved by the local IRB at each participating institution. Consent to participate: Consent for data collection was waived as this was a retrospective study. Consent for publication: N/A, no private health information is published in this manuscript. 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Patient demographics and lesion characteristics Patient Age Sex Pre-SLA KPS Pre-SLA corticosteroid Primary Tumor Location Lesion volume (cm 3 ) Prior WBRT Prior SRS dose (Gy) 1 67 F 90 Y Colon L thalamus 3.4 N 20 2 58 F 100 Y Melanoma L thalamus 4.5 N 20 3 54 F 90 Y Breast R thalamus 5.5 N 20 4* 60 F 80 Y Breast L frontal 3.2 N 20 4* 60 F 80 Y Breast L parietal 4.9 N 20 5 73 M 100 Y Lung R temporal 4.2 N 20 6 69 F 100 Y Ovarian L cerebellar 15.9 N 18 7 73 F 70 Y Urothelial L peri-atrial 35 N 18 8 53 F 100 Y Esophageal L temporal 4.5 N 20 9 34 M 70 Y Melanoma Rperi-atrial 34.2 N 18 10 66 F 80 Y Breast L parietal 27.1 N 18 11 66 F 60 Y Lung L cingulate 25.7 Y 18 12 58 F 90 Y SCC larynx R parietal 3.6 N 20 13 74 F 80 Y Lung L parietal 14 N 18 14 64 F 60 Y Breast L parietal 5.6 N 20 15 57 M 90 Y Colon L cerebellar 15 N 18 16 56 F 80 Y Lung L parietal 21 N 18 17 60 M 80 Y Esophageal R parietal 8.9 N 18 18 56 F 80 Y Undifferentiated L temporal 3.1 N 20 19 69 M 90 Y Lung L parietal 4.3 N 20 20 69 M 80 Y Lung L occipital 6 N 18 F : female. KPS : Karnofsky performance score prior to SLA. L : left. M : male. N : no. R : right. SCC : squamous cell carcinoma. WBRT : prior whole brain radiation therapy. Y : yes. *Two lesions treated in the same patient. Table 2. Stereotactic Laser Ablation and consolidation stereotactic radiosurgery (SLA/cSRS) Patient %oflesion ablated Days to cSRS Laser system cSRS cSRS modality 1 77.4 30 Monteris 5 Gy x 5 LINAC 2 74.6 23 Monteris 5 Gy x 5 LINAC 3 98.2 23 Monteris 5 Gy x 5 LINAC 4* 92.4 30 Monteris 5 Gy x 5 LINAC 4* 100 37 Monteris 5 Gy x 5 LINAC 5 100 23 Monteris 5 Gy x 5 LINAC 6 100 26 Visualase 5 Gy x 5 GK 7 73 16 Visualase 5 Gy x 5 GK 8 100 19 Visualase 5 Gy x 5 GK 9 97 30 Visualase 5 Gy x 5 GK 10 100 40 Visualase 5 Gy x 5 GK 11 100 27 Visualase 5 Gy x 5 GK 12 100 35 Monteris 5 Gy x 5 GK 13 92.4 27 Monteris 6 Gy x 5 GK 14 97.8 24 Monteris 5 Gy x 5 GK 15 99.2 20 Monteris 5 Gy x 5 GK 16 100 25 Monteris 6 Gy x 5 GK 17 99.3 20 Monteris 5 Gy x 5 GK 18 100 73 Monteris 5 Gy x 5 GK 19 90 24 Monteris 5 Gy x 5 GK 20 98 36 Monteris 5 Gy x 5 GK cSRS : consolidation stereotactic radiosurgery (dose x fractionation). Days to cSRS : days between stereotactic laser ablation and cSRS. Gy : Gray. GK: Gamma Knife. LINAC : linear accelerator. SLA : stereotactic laser ablation. % lesion ablated : Percentage of contrast enhancing region of BMRS covered by blue contour line (Monteris) or orange pixel (Visualase). *: two lesions treated in the same patient. Table 3. Clinical outcomes Patient Post-SLA deficit Post- SLA KPS Post-cSRS KPS Readmission LC Steroid (6 mo) Steroid (12 mo) FLAIR (6 mo) FLAIR (12 mo) 1 None 90 90 None Yes No No 2 None 100 100 None Yes No No 3 None 90 90 None Yes No No 4* None 80 80 None Yes No No 4* None 80 80 None Yes No No 5 None 100 100 None Yes No No 6 None 100 100 None Yes No No 7 None 50 50 Seizure Yes Yes** No 8 None 100 100 None Yes No No No No 9 None 70 70 None Yes No No 10 None 90 90 None Yes No No 11 None 100 100 HA Yes No No 12 None 70 70 None Yes Yes** No 13 None 80 80 None No Yes** No No No 14 None 70 70 None No No No No No 15 None 80 80 None Yes Yes** No 16 None 60 60 None Yes Yes** No 17 None 80 80 None Yes No No 18 None 80 80 None Yes No No No No 19 None 90 90 None Yes No No No No 20 None 80 80 None Yes No No cSRS : consolidation SRS. FLAIR : fluid attenuated inversion recovery. FLAIR (6 m) : Expansion of FLAIR volume 6 months after cSRS (compared to FLAIR volume at the time of BMRS diagnosis). FLAIR (12 m) : Expansion of FLAIR volume 12 months after cSRS (compared to FLAIR volume at the time of BMRS diagnosis). LC : local control. KPS : Karnofsky performance score. Mo : months. Post-SLA deficit : post-SLA neurological deficit. Post-SLA KPS : KPS on day post-SLA treatment. Post-cSRS KPS : KPS one-month post-cSRS. Readmission : cause of 30-day readmission. SLA : stereotactic laser ablation. Steroid (6 m) : corticosteroid treatment 6 months after cSRS. Steroid (12 m) : corticosteroid treatment 12 months after cSRS. SRS : stereotactic radiosurgery. *: two lesions treated in the same patient. **: corticosteroid was used to treat symptoms related to other brain metastases and unrelated to the SLA/cSRS treated BMRS. Table 4. Outcomes of SLA and repeat radiosurgery monotherapy A. SLA Reference Number of patients Local control Ali et al. 2016 [13] 23 61% at 4.6 months Ahluwalia et al. 2018 [14] 20 74% at 3 months Bastos et al. 2020 [15] 61 69.6% at 12 months B. Repeat SRS Reference # of patients # of BMRS Median SRS dose (Gy) fractions of SRS LC 12 Adverse radiation effect Holt et al. 2015 [30] 15 15 21 3 75% 13% Minniti et al. 2016 [10] 43 43 21 3 70% 19% Rana et al. 2017 [31] 32 32 26.5 3 88% 19% Dincoglan et al. 2019 [32] 30 30 21 3 835 13% A : Studies reporting stereotactic laser ablation as monotherapy for the treatment of brain metastasis that recurred locally afterradiosurgery (BMRS). B : Studies reporting repeat radiosurgery as monotherapy for the treatment of BMRS. SRS : stereotactic radiosurgery. LC 12 : local control at 12-months follow-up. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-794328","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":44735479,"identity":"bded3dba-344c-4e7c-9424-83137d05ecf6","order_by":0,"name":"Isabela Peña Pino","email":"","orcid":"","institution":"University of Minnesota Medical Center Fairview: University of Minnesota Health","correspondingAuthor":false,"prefix":"","firstName":"Isabela","middleName":"Peña","lastName":"Pino","suffix":""},{"id":44735480,"identity":"13b3f341-5af5-4537-80c8-4bb564ce7802","order_by":1,"name":"Jun Ma","email":"","orcid":"","institution":"University of Minnesota Medical Center Fairview: University of Minnesota Health","correspondingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Ma","suffix":""},{"id":44735481,"identity":"7c53dc4f-00b5-4f86-9dec-a3151e8c4aac","order_by":2,"name":"Yusuke Hori","email":"","orcid":"","institution":"Cleveland Clinic Lerner College of Medicine of CWRU: Cleveland Clinic Lerner College of Medicine of Case Western Reserve University","correspondingAuthor":false,"prefix":"","firstName":"Yusuke","middleName":"","lastName":"Hori","suffix":""},{"id":44735482,"identity":"a10dd118-3b10-4506-a2b8-a5df2550c44a","order_by":3,"name":"Elena Fomchenko","email":"","orcid":"","institution":"Yale University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Elena","middleName":"","lastName":"Fomchenko","suffix":""},{"id":44735483,"identity":"9a850273-0428-46c6-9f0f-0c466ecebfc5","order_by":4,"name":"Kathryn Dusenbery","email":"","orcid":"","institution":"University of Minnesota Medical Center Fairview: University of Minnesota Health","correspondingAuthor":false,"prefix":"","firstName":"Kathryn","middleName":"","lastName":"Dusenbery","suffix":""},{"id":44735484,"identity":"0b994f06-372c-4b59-a541-de8750b51a3b","order_by":5,"name":"Margaret Reynolds","email":"","orcid":"","institution":"University of Minnesota Medical Center Fairview: University of Minnesota Health","correspondingAuthor":false,"prefix":"","firstName":"Margaret","middleName":"","lastName":"Reynolds","suffix":""},{"id":44735485,"identity":"b17c6ac2-9bdd-4de3-988a-6e787e57fd66","order_by":6,"name":"Christopher Wilke","email":"","orcid":"","institution":"University of Minnesota Medical Center Fairview: University of Minnesota Health","correspondingAuthor":false,"prefix":"","firstName":"Christopher","middleName":"","lastName":"Wilke","suffix":""},{"id":44735486,"identity":"7956354d-de17-47de-9e43-a7b1cbdcd796","order_by":7,"name":"Jianling Yuan","email":"","orcid":"","institution":"University of Minnesota Medical Center Fairview: University of Minnesota Health","correspondingAuthor":false,"prefix":"","firstName":"Jianling","middleName":"","lastName":"Yuan","suffix":""},{"id":44735487,"identity":"939af27a-5fdc-40da-a124-18b86ffc5ce3","order_by":8,"name":"Ethan Srinivasan","email":"","orcid":"","institution":"Duke University Medical Center: Duke University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ethan","middleName":"","lastName":"Srinivasan","suffix":""},{"id":44735488,"identity":"cad44276-fcd0-4e32-9871-bd4b09c8af1f","order_by":9,"name":"Matthew Grabowski","email":"","orcid":"","institution":"Duke University Medical Center: Duke University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Matthew","middleName":"","lastName":"Grabowski","suffix":""},{"id":44735489,"identity":"4de134ba-d3eb-465e-9749-97271e18f3d2","order_by":10,"name":"Peter Fecci","email":"","orcid":"","institution":"Duke University Medical Center: Duke University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Peter","middleName":"","lastName":"Fecci","suffix":""},{"id":44735490,"identity":"4202e069-c2eb-4ad1-a157-8445a426bca9","order_by":11,"name":"Evidio Domingo-Musibay","email":"","orcid":"","institution":"University of Minnesota Medical Center Fairview: University of Minnesota Health","correspondingAuthor":false,"prefix":"","firstName":"Evidio","middleName":"","lastName":"Domingo-Musibay","suffix":""},{"id":44735491,"identity":"4aa77e7a-ef8d-4bb7-af3f-dcf0e6b0de3b","order_by":12,"name":"Naomi Fujioka","email":"","orcid":"","institution":"University of Minnesota Medical Center Fairview: University of Minnesota Health","correspondingAuthor":false,"prefix":"","firstName":"Naomi","middleName":"","lastName":"Fujioka","suffix":""},{"id":44735492,"identity":"aa6e4f67-b50d-4792-8374-39826d8caa7a","order_by":13,"name":"Gene H. Barnett","email":"","orcid":"","institution":"Cleveland Clinic Lerner College of Medicine of CWRU: Cleveland Clinic Lerner College of Medicine of Case Western Reserve University","correspondingAuthor":false,"prefix":"","firstName":"Gene","middleName":"H.","lastName":"Barnett","suffix":""},{"id":44735493,"identity":"b33de381-0ca0-495e-bdbd-63815b02c975","order_by":14,"name":"Veronica Chang","email":"","orcid":"","institution":"Yale University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Veronica","middleName":"","lastName":"Chang","suffix":""},{"id":44735494,"identity":"2d2af670-47f5-4489-be5e-56c105dabc7a","order_by":15,"name":"Alireza M. Mohammadi","email":"","orcid":"","institution":"Cleveland Clinic Lerner College of Medicine of CWRU: Cleveland Clinic Lerner College of Medicine of Case Western Reserve University","correspondingAuthor":false,"prefix":"","firstName":"Alireza","middleName":"M.","lastName":"Mohammadi","suffix":""},{"id":44735495,"identity":"6c0f18cb-6a7b-4317-993a-ce36d3e7274a","order_by":16,"name":"Clark C Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAmklEQVRIiWNgGAWjYHACNiC2gTB5SNCSRrqWwyRo4W8//OzBxx3nE9fObmB88LaNCC0SZ9LMDWeeuZ247c4BZsO5xGgxkOBhk+ZtA2q5kQBiEKvlb9s5kBb238RrYWw7ALaFmSgtQL+YSfa2JRtvu5HYLDnnHBFaQCEm8bPNTnbbjeSDH96UEaEFCTA2kKZ+FIyCUTAKRgFuAAAd3zTQLtJBIgAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0001-6258-9277","institution":"University of Minnesota Health","correspondingAuthor":true,"prefix":"","firstName":"Clark","middleName":"C","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2021-08-09 03:38:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-794328/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-794328/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":12347614,"identity":"9ce8194a-3a27-4eaf-a93f-39d45f0fece4","added_by":"auto","created_at":"2021-08-11 21:26:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":931762,"visible":true,"origin":"","legend":"Representative consolidation stereotactic radiosurgery (cSRS) plans. Hypo-fractionated radiosurgery (5 Gy x 5) targeting the post-ablative region, including the rim of contrast enhancement was delivered. Radiosurgery plans for patient 8 (Figure 2A) and 9 (Figure 2B) are shown.","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-794328/v1/0302bfc4fd36a8a55200a50a.png"},{"id":12347611,"identity":"89845093-311e-45f3-90ea-eb48c5421d58","added_by":"auto","created_at":"2021-08-11 21:26:16","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":69707,"visible":true,"origin":"","legend":"A: local control of brain metastasis that recurred locally after initial radiosurgery (BMRS) after Stereotactic Laser Ablation (SLA) followed by consolidation stereotactic radiosurgery (cSRS). B: overall survival of the study cohort.","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-794328/v1/b3ba7eb211cdc15d137e9e68.png"},{"id":12347612,"identity":"240fc659-de3d-4d5e-9477-03c9ff6168e0","added_by":"auto","created_at":"2021-08-11 21:26:16","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":239302,"visible":true,"origin":"","legend":"Sequential evolution of contrast enhancement and FLAIR volume (axial T1, axial FLAIR, coronal T1, sagittal T1, respectively from top to bottom) for representative SLA/cSRS treated lesion in patient 8. This patient’s BMRS remain controlled 19 months after SLA/cSRS. SRSi: initial SRS. BMRS was diagnosed one-year after the initial SRS. 3 m f/u: 3 months follow-up, 6 m f/u: 6 months follow-up, 19 m f/u: 19 months follow-up.","description":"","filename":"FIgure3.png","url":"https://assets-eu.researchsquare.com/files/rs-794328/v1/3224afbc696ad10decf04503.png"},{"id":12347613,"identity":"566a1dab-e880-4782-8604-7ab7246e0532","added_by":"auto","created_at":"2021-08-11 21:26:16","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":218640,"visible":true,"origin":"","legend":"Sequential evolution of local recurrence for patient 14. Contrast enhancement and FLAIR volume (axial T1, axial FLAIR, coronal T1, sagittal T1, respectively from top to bottom) demonstrate increase in contrast enhancement size and FLAIR volume at 22 months post SLA/cSRS. SRSi: initial SRS. BMRS was diagnosed 32 months after the initial SRS. 3 m f/u: 3 months follow-up, 6 m f/u: 6 months follow-up, recurrence (22m): tumor recurrence 22 months after SLA/cSRS.","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-794328/v1/e393f1d0b3076e2e89182652.png"},{"id":13708852,"identity":"80867233-0f3d-4501-8fd9-d879c3932ee3","added_by":"auto","created_at":"2021-09-17 14:10:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1924331,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-794328/v1/e10d3669-8e08-499b-ac40-fab00ba9cb89.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eStereotactic Laser Ablation (SLA) Followed by Consolidation Stereotactic Radiosurgery (cSRS) as Treatment for Brain Metastasis that Recurred Locally After Initial Radiosurgery (BMRS): A Multi-Institutional Experience\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn independent randomized clinical trials, ~30% of BM recur locally after radiosurgery twelve months after treatment \u003ca href=\"https://paperpile.com/c/kVeEHJ/Hd4U\"\u003e[1]\u003c/a\u003e. The local recurrence rate is higher for BM intrinsically resistant to radiation \u003ca href=\"https://paperpile.com/c/kVeEHJ/2yDj+ueiz\"\u003e[2, 3]\u003c/a\u003eor those with up-regulated DNA repair capacity \u003ca href=\"https://paperpile.com/c/kVeEHJ/LPv1+26at+gdZn\"\u003e[4\u0026ndash;6]\u003c/a\u003e. There is currently no consensus on the optimal treatment strategy for brain metastasis that recur after radiosurgery (BMRS). Repeat radiosurgery to BMRS is often employed in this context. However, such treatments are associated with an increased risk for neurologic decline secondary to adverse radiation effects, including radiation necrosis\u003ca href=\"https://paperpile.com/c/kVeEHJ/QNOR+6Cwa\"\u003e[7, 8]\u003c/a\u003e. These repeat radiation-associated deleterious effects can compromise the patient\u0026rsquo;s quality of life, delay systemic therapy, or necessitate surgical interventions \u003ca href=\"https://paperpile.com/c/kVeEHJ/6Cwa+mz6k\"\u003e[8, 9]\u003c/a\u003e. Moreover, up to 30% of repeat radiosurgery fail to achieve local control of BMRS \u003ca href=\"https://paperpile.com/c/kVeEHJ/Bu1f\"\u003e[10]\u003c/a\u003e.\u003c/p\u003e\n\u003cp\u003eStereotactic laser ablation (SLA, also known as laser interstitial thermal therapy (LITT)) refers to a procedure whereby a fiberoptic laser probe is stereotactically inserted into a target abnormality in the brain or spine \u003ca href=\"https://paperpile.com/c/kVeEHJ/mjie\"\u003e[11]\u003c/a\u003e. Activation of the probe induces hyperthermia within the target tissue, causing coagulative necrosis \u003ca href=\"https://paperpile.com/c/kVeEHJ/mjie\"\u003e[11]\u003c/a\u003e. While SLA has been employed as a treatment for newly diagnosed BM, the clinical outcomes have been disappointing, with 30-50% local failure within twelve months of treatment \u003ca href=\"https://paperpile.com/c/kVeEHJ/XRM8+IrfZ+w99G+eCV2\"\u003e[12\u0026ndash;15]\u003c/a\u003e. Despite these results, there are reasons to consider SLA in combination with repeat radiosurgery as a treatment strategy for BMRS. First, there is sound laboratory science \u003ca href=\"https://paperpile.com/c/kVeEHJ/rhNl\"\u003e[16]\u003c/a\u003e, pre-clinical \u003ca href=\"https://paperpile.com/c/kVeEHJ/uIee\"\u003e[17]\u003c/a\u003e, and clinical data \u003ca href=\"https://paperpile.com/c/kVeEHJ/YwAF+SN1c+3xVH\"\u003e[18\u0026ndash;20]\u003c/a\u003e suggesting synergy in the anti-tumoral effects of hyperthermia and radiation. This synergy warrant consideration given the radiation resistant nature of BMRS. Second, SLA is a highly effective treatment for radiosurgery associated adverse radiation effects \u003ca href=\"https://paperpile.com/c/kVeEHJ/yKAN+w99G+81rt\"\u003e[14, 21, 22]\u003c/a\u003e. The available literature suggests that SLA inactivates immune cells and/or denatures inflammatory cytokines that mediate radiation-induced injuries \u003ca href=\"https://paperpile.com/c/kVeEHJ/4y6j\"\u003e[23]\u003c/a\u003e. Thus, the addition of SLA to repeat SRS can potentially mitigate risk of subsequent adverse radiation effects.\u003c/p\u003e\n\u003cp\u003eIn this context, we previously reported results from four BMRS patients treated with SLA followed by cSRS in 2016 \u003ca href=\"https://paperpile.com/c/kVeEHJ/IrfZ\"\u003e[13]\u003c/a\u003e. Here, we report a larger multi-institutional experience examining the efficacy and safety profile of this treatment strategy for patients with \u0026gt; 6 months follow-up.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003ePatient population and data collection\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study was a multi-institutional, retrospective case series of patients who underwent SLA/cSRS between 2012 and 2020 for needle biopsy-confirmed brain metastasis recurrence after initial SRS treatment. Each of the participating institutions holds an approved IRB for this retrospective review. To characterize longer-term effects of SLA/cSRS, we included only patients who had 6 months follow-up data. Demographic and clinical data collected from the electronic record system included: sex, age at BMRS presentation, primary tumor subtype, tumor location, tumor volume, prior whole brain radiation therapy (WBRT), 30-day readmission, and SLA/cSRS associated morbidity (including radiation induced adverse effects). Baseline and post-SLA/cSRSKarnofsky Performance Status (KPS) and steroid use were collected for all patients at time of BMRS diagnosis, one day post-SLA, one monthpost-cSRS, and at subsequent follow-up visits. As per standard of care, patients were seen by the neurosurgeon ~ 2 weeks after SLA. Patients were seen by the radiation oncologist one month after cSRS and every 2-3 months thereafter. Follow-up duration was calculated from the time of cSRS.Overall Survival was calculated from the time of initial cancer diagnosis.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMRI analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll patients underwent surveillance MRI every 2-3 months unless imaging or clinical findings warranted shorter interval follow-up. MRIs from each site are reviewed by two independent assessors. MRIs were obtained before and after treatment and imported into the Brainlab (BrainlabAG,Munich, Germany)iPlan Cranial 3.0 software or 3D Slicer (\u003ca href=\"http://www.slicer.org\"\u003ewww.slicer.org\u003c/a\u003e) or image J (\u003ca href=\"https://imagej.nih.gov/ij/\"\u003ehttps://imagej.nih.gov/ij/\u003c/a\u003e) to determine maximal diameter and volume. The volume of contrast enhancing (CE) and FLAIR volumes surrounding the SLA/cSRS treated lesion were recorded immediately post-SLA and for each imaging follow-up. Local control (LC) was defined using modified RANO-BM criteria \u003ca href=\"https://paperpile.com/c/kVeEHJ/5Vu7\"\u003e[24]\u003c/a\u003e, as described below. Since the SLA ablated region often show expansion of contrast enhancement immediately post-procedure that resolves in the subsequent one to three months \u003ca href=\"https://paperpile.com/c/kVeEHJ/aqMF\"\u003e[25]\u003c/a\u003e, we define local failure as persistent increase of \u0026gt; 20% in the size of contrast enhancement (based on RANO-BM) relative to the time of BMRS presentation, on two sequential MRIs that were greater than three months apart (similar to immunotherapy RANO \u003ca href=\"https://paperpile.com/c/kVeEHJ/FuH6\"\u003e[26]\u003c/a\u003e). Lesions demonstrating such local failure were surgically excised for definitive tissue diagnosis.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSLA and consolidation SRS\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBMRS patients considered for SLA/cSRS were reviewed at a multi-disciplinary board consisting of representatives from neuro-oncology, neurosurgery, radiation oncology, neuroradiology, and neuropathology. Informed consents were obtained by neurosurgery and radiation oncology. The SLA procedures were performed as previously described \u003ca href=\"https://paperpile.com/c/kVeEHJ/IrfZ\"\u003e[13]\u003c/a\u003e. For lesions treated with the NeuroBlate system (Monteris Medical Inc., Plymouth, MN, USA), extent of ablation was assessed based on CE region covered by blue contour line (equivalent to of tissue heating to 43\u003csup\u003eo\u003c/sup\u003eC for \u0026gt; 10 minutes) \u003ca href=\"https://paperpile.com/c/kVeEHJ/sUXv\"\u003e[27]\u003c/a\u003e. For lesions treated with the Visualase system (Medtronics Inc., Minneapolis, MN), extent of ablation was assessed based on CE region covered by orange pixel (equivalent to tissue injury achieved at 60\u003csup\u003eo\u003c/sup\u003eC).\u003c/p\u003e\n\u003cp\u003eConsolidation SRS was carried out approximately one to two months after the SLA and delivered through five consecutive fractions of 5 Gy or 6 Gy. SRS treatment was performed using either the Leksell Gamma Knife Icon (Elekta Instrument AB, Stockholm, Sweden) or the TrueBeam linear accelerator (Varian Medical Systems, Palo Alto, California). The planned target volume (PTV) was defined by the entirety of the ablated lesion, including, regions of contrast enhancement (\u003cstrong\u003eFigure 1\u003c/strong\u003e). For Icon-treated patients, PTV was prescribed to the 50% isodose. For the TrueBeam treated patients, PTV was prescribed to the 90% isodose.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLiterature search and statistical analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe literature search was performed in June 2021, reviewed by the first author (IP) and senior author (CCC). For assessment of the published literature for SLA as treatment for BMRS, we repeated a search strategy that we had previously implemented in 2018 \u003ca href=\"https://paperpile.com/c/kVeEHJ/IrfZ\"\u003e[13]\u003c/a\u003e. In this search, we identified two publications bearing information on the local control of BMRS after SLA. For assessment of the published literature for hypo-fractionated repeat SRS as treatment for BMRS, we repeated a published strategy that was implemented in 2019 by Loi et al \u003ca href=\"https://paperpile.com/c/kVeEHJ/pYgs\"\u003e[28]\u003c/a\u003e. We identified four publications bearing pertinent local control and adverse radiation effect information following repeat, hypo-fractionated radiosurgery of BMRS.\u003c/p\u003e\n\u003cp\u003eGraphPad Prism Version 9 was used for all statistical analyses (GraphPad Software, San Diego, California). Categorical and continuous data are described as frequency (percentage) and median (interquartile range), respectively. Fisher\u0026rsquo;s exact test and the Mann-Whitney U-test were used for the univariate analyses of categorical and continuous data, respectively.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eStudy population\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study cohort consists of six male and thirteen female patients. The median age of the cohort was 64 years old (range: 34-74). The histology of the BMs treated included: lung (n=6), breast (n=5), gastrointestinal (n=3), melanoma (n=2), laryngeal (n=1), urothelial (n=1), ovarian (n=1), and undifferentiated (n=1). The medianCE tumor volume at the time of BMRS presentation was 5.6 cm\u003csup\u003e3\u003c/sup\u003e (range: 3.1-34.2 cm\u003csup\u003e3\u003c/sup\u003e). All lesions were deemed difficult to access surgically by the treating neurosurgeon and underwent stereotactic needle biopsies, with pathology confirming BMRS. All lesions received 18-21 Gy of single fraction SRS at the time of initial diagnosis. The locations of the lesions as well as other demographic and tumor characteristics are shown in \u003cstrong\u003eTable 1\u003c/strong\u003e. Except for patient 11, who was treated with WBRT two years prior to the initial SRS, none of the patients received prior WBRT. Patient 4 underwent two separate SLA/cSRS for lesions located in the frontal and parietal lobe, identified approximately six months apart. All other patients underwent a single SLA/cSRS. All patients were treated with corticosteroid following the BMRS diagnosis and prior to SLA. All patients underwent subsequent systemic therapy.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSLA/cSRS and post-operative course\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe volume of BMRS CE ablated was as defined in Methods. Seventy-three to 100 % of the BMRS CE volume was ablated at the time of SLA (\u003cstrong\u003eTable 2\u003c/strong\u003e). There were no new neurologic deficits immediately post-SLA or at the one-month follow-up. Consistent with previously published SLA series \u003ca href=\"https://paperpile.com/c/kVeEHJ/w99G+cLjM\"\u003e[14, 29]\u003c/a\u003e, the KPS of 80% (16/20) of the patients remain unchanged after SLA. Three of 20 (15%) suffered a temporary decline in KPS post-SLA, while 1/20 (5%) showed an improvement in KPS. All patients were discharged home within two days of SLA. There was no operative morbidity or mortality attributable to the SLA.\u003c/p\u003e\n\u003cp\u003eConsolidation SRSwas performed one to two months after SLA and was performed as an out-patient procedure. The median time from SLA to cSRS was 26 days (range 16-73 days).\u0026nbsp;The median BMRS CE volume for this series was 5.6 cm\u003csup\u003e3\u003c/sup\u003e. cSRS was targeted the post-ablative region, including the rim of contrast enhancement (\u003cstrong\u003eFigure 1\u003c/strong\u003e). Eighteen of 20 (90%) of the patients were treated with a 5 Gy x 5 consecutive day regimen, and 2 patients were treated with a 6 Gy x 5 consecutive day regimen. By the time of cSRS, the three patients who suffered a KPS decline after SLA had recovered to their baseline KPS. All KPS remained stable at one-month post-cSRS.\u003c/p\u003e\n\u003cp\u003eThere were two 30-day post-SLA readmissions. Patient 7 presented with an incapacitating headache in the context of corticosteroid dose. The headache resolved after a temporary re-escalation of corticosteroid treatment. Patient 11 presented with a new-onset seizure and was placed on levetiracetam and a short course of corticosteroid. Of note, patient 11 is the only patient in this series who received WBRT prior to initial SRS. Head CT\u0026rsquo;s for both patients were without evidence of tumor hemorrhage but showed increased per-BMRS hypodensity. Both patients were discharged by hospital day 2. Of note, both admitted patients harbored BMRS that is larger than the median volume of the tumor treated in this series. The median BMRS CE volume for this series was 5.6 cm\u003csup\u003e3\u003c/sup\u003e; the BMRS CE volumes for patients 7 and 11 were 35 cm\u003csup\u003e3\u003c/sup\u003e and 25.7 cm\u003csup\u003e3\u003c/sup\u003e, respectively.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eImaging and clinical follow-up\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFollow-up duration and local control was calculated from the time of cSRS.The median follow-up for this cohort is 228 days (range: 183-1367 days).\u0026nbsp;There were two treatment failures that occurred 1367 and 1161 days after SLA/cSRS (patients 13 and 14, \u003cstrong\u003eFigure 2A\u003c/strong\u003e). Overall survival was calculated from the time of the cancer diagnosis. The median survival for this study cohort was 378 days (\u003cstrong\u003eFigure 2B\u003c/strong\u003e).Six months follow-up was available for all patients (\u003cstrong\u003eTable 3\u003c/strong\u003e). At six months, the CE volumes for all SLA/cSRS treated lesions were decreased relative to the time of SLA. Similarly, the peri-CE FLAIR volumes for all treated lesionsdecreased relative to the initial BMRS presentation. Six months after SLA/cSRS, five out of 20 (25%) of the patients continued to be treated with corticosteroid. Based on both clinical documentation and surveillance MR imaging, the corticosteroid was used to treat symptoms related to other BM and unrelated to the SLA/cSRS treated BMRS,\u003c/p\u003e\n\u003cp\u003eTwelve-month follow-up was available for five patients. Local control at twelve months (LC\u003csub\u003e12\u003c/sub\u003e) was 100%, and the peri-CE FLAIR volumes remained decreased for the treated lesions relative to the time of SLA. None of the patients required corticosteroid treatment. Two illustrative cases are shown in \u003cstrong\u003eFigures 3\u003c/strong\u003eand \u003cstrong\u003e4\u003c/strong\u003e. \u003cstrong\u003eFigure 3\u003c/strong\u003eshows the evolution of CE and FLAIR after SLA/cSRS in the longest surviving patient (patient 8) whose BMRS remain controlled 19 months after SLA/cSRS.\u0026nbsp;\u003cstrong\u003eFigure 4\u003c/strong\u003e shows the evolution of CE and FLAIR after SLA/cSRS in a patient (patient 14) whose BMRS recurred 1161 days(~39 months) after SLA/cSRS.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLiterature of efficacy of repeat radiosurgery and stereotactic laser ablation (SLA)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe wishto compare our case series to the published literature for salvage monotherapy using either SLA or repeat SRS for BMRS. The literature search for SLA treated BMRS (see Methods for the search algorithm) yielded one study that reported a local control of 61% at 4.6 months \u003ca href=\"https://paperpile.com/c/kVeEHJ/IrfZ\"\u003e[13]\u003c/a\u003e. Broadening our search to include case series that include a mixture of pathology confirmed BMRS, newly diagnosed BMRS, and radiation necrosis, we identified two additional studies. The study by Ahluwalia et al. consisted of 22 pathology-confirmed BMRS and 22 radiation necrosis. Only three-month local control was reported (LC\u003csub\u003e3\u003c/sub\u003e), and the reported LC\u003csub\u003e3\u003c/sub\u003e was 37% [14]. The second study by Bastos et al. consisted of 46 BMRS and 5 newly diagnosed BM. The reported LC\u003csub\u003e12\u003c/sub\u003e was 69.6% for this series \u003ca href=\"https://paperpile.com/c/kVeEHJ/eCV2\"\u003e[15]\u003c/a\u003e (Table 4A).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSince our cSRSused a hypo-fractionated regimen, we focused our literature search to identify articles that studied the efficacy and safety of hypo-fractionated repeat SRS as a treatment for BMRS. We identified four such articles (Table 4B) \u003ca href=\"https://paperpile.com/c/kVeEHJ/3RCr+Bu1f+oU2f+D0TW\"\u003e[10, 30\u0026ndash;32]\u003c/a\u003e. The reported local control at 12 months ranged 70-83%, with 13-19% of the patients suffering from symptomatic adverse radiation effects after repeat radiation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe LC\u003csub\u003e12\u003c/sub\u003e of 100% and 0% adverse radiation effects at 6 and 12 months after SLA/cSRS treatment of BMRS in our series compares favorably to these reported results.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur literature search suggests that the treatment of BMRS remains an understudied area in neuro-oncology. The overall poor survival of BM patients \u003ca href=\"https://paperpile.com/c/kVeEHJ/qjfk\"\u003e[33]\u003c/a\u003e likely contributes to this limited literature. Many BM patients die before developing recurrence. However, as newer classes of systemic therapies emerge and improve cancer survival, there will be a greater need for meaningful therapeutic interventions in the treatment of BMRS \u003ca href=\"https://paperpile.com/c/kVeEHJ/R2kn\"\u003e[34]\u003c/a\u003e. Here, we retrospectively analyzed a multi-institutional experience that employed SLA/cSRS as a treatment strategy for BMRS. This study builds on and expands on the clinical outcome of the four patients reported in our 2016 study \u003ca href=\"https://paperpile.com/c/kVeEHJ/IrfZ\"\u003e[13]\u003c/a\u003e. By expanding the number of patients treated as well as lengthening the follow-up duration (to \u0026gt; 6 months), we provide data to support the safety profile and durable efficacy of SLA/cSRS as treatment for BMRS.\u003c/p\u003e\n\u003cp\u003eOur current study suggests that the procedural safety profile of SLA/cSRS is comparable to that reported for SLA alone \u003ca href=\"https://paperpile.com/c/kVeEHJ/w99G+IrfZ+5jP0\"\u003e[13, 14, 35]\u003c/a\u003e. Because of the limited BMRS literature, we were unable to perform a meaningful, quantitative comparison between the results of this study to the available literature. Qualitatively, the LC\u003csub\u003e6\u003c/sub\u003e and LC\u003csub\u003e12\u003c/sub\u003e of 100% after SLA/cSRS for tissue confirmed BMRS in our series compares favorably to the reported LC\u003csub\u003e12\u003c/sub\u003e of 69.6% \u003ca href=\"https://paperpile.com/c/kVeEHJ/eCV2\"\u003e[15]\u003c/a\u003e for SLA alone. Of note, this SLA study included a mixed population of BMRS and newly diagnosed BM, with the latter presumably more radiation sensitive than the former. The local control of BMRS by SLA/cSRS also compares favorably to the 70-83% reported for repeat hypo-fractionated SRS. These results should be interpreted with the following consideration. While it is unlikely that any practitioner would purposely treat non-recurrent BM with repeat radiosurgery, the imaging methods available for assessing recurrent BM versus adverse radiation effects following radiosurgery remain imperfect \u003ca href=\"https://paperpile.com/c/kVeEHJ/Lxoz\"\u003e[36]\u003c/a\u003e. As such, it is possible that a subset of the lesions thought to be BMRS on imaging may represent post-radiosurgery radiation effects. If so, the published study of BMRS without tissue diagnosis reports local control rates that may be artificially inflated \u003ca href=\"https://paperpile.com/c/kVeEHJ/o83U\"\u003e[37]\u003c/a\u003e.\u0026nbsp;In this context, it is notable that all BMRS in this series were confirmed by tissue.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother advantage of the SLA/cSRS treatment paradigm is highlighted by the absence of adverse radiation effects in our series compared to the13-19% reported withrepeat radiosurgery of BMRS. The neurologic sequelae of these adverse effects compromise the patient\u0026rsquo;s quality of life, requiring corticosteroid therapy, surgical therapy, or both. Since innate anti-tumoral responses play a key role in the efficacy of nearly all anti-cancer therapies, immune suppression secondary to corticosteroid administration may compromise the efficacy of systemic therapies \u003ca href=\"https://paperpile.com/c/kVeEHJ/oqmf\"\u003e[38]\u003c/a\u003e. Moreover, the advent of immunotherapy and targeted therapy has increased the risk for SRS-associated adverse radiation effects \u003ca href=\"https://paperpile.com/c/kVeEHJ/mACH+W0DC\"\u003e[39, 40]\u003c/a\u003e. As many as one in five melanoma BM patients treated with nivolumab and ipilimumab suffers adverse radiation effects after SRS, requiring cessation of systemic therapy \u003ca href=\"https://paperpile.com/c/kVeEHJ/W0DC\"\u003e[40]\u003c/a\u003e. Minimizing the risk of such cessation has the potential to improve therapeutic efficacy of systemic therapy. In this context, the absence of adverse radiation effects in our SLA/cSRS series despite repeat radiosurgery to the same lesion suggests that SLA may minimize the risk of adverse radiation effects,rendering the treatment strategy attractive.\u003c/p\u003e\n\u003cp\u003eThe imaging findings after SLA-cSRS are complex and worth noting. MRIs performed immediately post-SLA typically show an expansion in CE volume, accompanied by an enlargement of the surrounding FLAIR \u003ca href=\"https://paperpile.com/c/kVeEHJ/5jP0+sUXv\"\u003e[27, 35]\u003c/a\u003e. While many SLA-treated lesions show egg-shell contrast enhancement (\u003cstrong\u003eFigures 3\u003c/strong\u003e and \u003cstrong\u003e4\u003c/strong\u003e), others exhibit more heterogeneous enhancement patterns \u003ca href=\"https://paperpile.com/c/kVeEHJ/IrfZ+tQC4+XRM8\"\u003e[12, 13, 41]\u003c/a\u003e. These SLA-associated MR changes typically resolve one to three months post-SLA \u003ca href=\"https://paperpile.com/c/kVeEHJ/5jP0+IrfZ+tQC4+XRM8\"\u003e[12, 13, 35, 41]\u003c/a\u003e. As such, assessment of MR at any single time point after SLA, such as that described by RANO-BM \u003ca href=\"https://paperpile.com/c/kVeEHJ/VVue\"\u003e[42]\u003c/a\u003e, is inadequate for assessing tumor control. In this context, we modified the RANO-BM criteria to include the sequential surveillance MRIs, similar to that proposed for immunotherapy RANO (iRANO) \u003ca href=\"https://paperpile.com/c/kVeEHJ/FuH6\"\u003e[26]\u003c/a\u003e. We considered local failure only if the \u003cu\u003e\u0026gt;\u003c/u\u003e20% increase in CE volume remained persistent on MRIsscanned three months apart. The pilot data presented in our series support the utility of this proposed modification. Of the two cases (patient 13 and 14) that showed tumor progression at later time points based on the above proposed criteria, both underwent surgical resection, with specimens confirming tumor progression.\u003c/p\u003e\n\u003cp\u003eAn important consideration in patient selection for SLA involves the volume of the BMRS. Post-SLA edema is a well-documented phenomenon that can lead to morbidities and mortalities \u003ca href=\"https://paperpile.com/c/kVeEHJ/IrfZ+5jP0\"\u003e[13, 35]\u003c/a\u003e. In this context, the larger lesions treated in this series involved patients with either cerebral atrophy or who had undergone previous surgical resections. The atrophy or resection reduce cerebral volume to increase capacity for tolerating post-SLA edema. Despite the cautions exercised in patient selection, two of the patients (patient 7 and 11) with larger BMRS suffered 30-day readmission after SLA/cSRS for symptoms attributable to treated BMRS. Patient 11\u0026rsquo;s prior history of WBRT further suggest that the cumulative radiation dose may influence cerebral compliance and tolerance of post-SLA edema. As such, judicious consideration in patient selection and close follow-up of SLA/cSRS treated patients is warranted, especially for patients with larger tumor volumes or patients who had undergone multiple rounds of prior RT/SRS.\u003c/p\u003e\n\u003cp\u003eAs a retrospective analysis, our conclusions are subject to the influences of all forms of biases inherent within this study design \u003ca href=\"https://paperpile.com/c/kVeEHJ/sUXv\"\u003e[27]\u003c/a\u003e. Moreover, all BMRS presented in this series underwent SLA that achieved \u0026gt;70% ablation of the contrast enhancing tumor volume. As such, the results reported here may not be applicable if such extent of ablation was not achieved. Ultimately, a randomized control trial (RCT) will be needed to validate the results reported here. If the pilot safety and efficacy profiles reported here are recapitulated in an RCT, the results can contribute to a new standard of care for BMRS patients. While this case series focused exclusively on patients with recurrent BM, the approach should be applicable to other clinical contexts, including the treatment of BM with a high probability of SRS failure, such as larger volume melanoma BM in the upfront setting.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis multi-institutional experience provides pilot safety and efficacy data for hypo-fractionated SRS within two months of SLA treatment of BMRS and support continued investigation of this treatment strategy. The results described here informs the design of future randomized clinical trials.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFunding: No funding was provided for this study.\u003c/p\u003e\n\u003cp\u003eConflicts of interest: The authors do not have any conflicts of interest to report\u003c/p\u003e\n\u003cp\u003eAvailability of data: Data will be made available upon request as deemed appropriate by the corresponding author\u003c/p\u003e\n\u003cp\u003eCode availability: N/A\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions: JM, YH, EF, KD, MR, CW, JY, ES, MG, PF, EDM, NF, GHB, VC and AM collected data. IPP drafted the manuscript. CCC conceived the study, performed procedures reported, drafted the manuscript. All authors edited the final draft of the manuscript and provided critical review.\u003c/p\u003e\n\u003cp\u003eEthics approval: This study was approved by the local IRB at each participating institution.\u003c/p\u003e\n\u003cp\u003eConsent to participate: Consent for data collection was waived as this was a retrospective study.\u003c/p\u003e\n\u003cp\u003eConsent for publication: N/A, no private health information is published in this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRoberge D, Brown PD, Whitton A, et al (2018) The Future Is Now-Prospective Study of Radiosurgery for More Than 4 Brain Metastases to Start in 2018! Front Oncol 8:380\u003c/li\u003e\n\u003cli\u003eDouglas JG, Margolin K (2002) The treatment of brain metastases from malignant melanoma. Semin Oncol 29:518\u0026ndash;524\u003c/li\u003e\n\u003cli\u003eChrist SM, Mahadevan A, Floyd SR, et al (2015) Stereotactic radiosurgery for brain metastases from malignant melanoma. 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Lancet Oncol 16:e270\u0026ndash;8\u003c/li\u003e\n\u003cli\u003eBeechar VB, Prabhu SS, Bastos D, et al (2018) Volumetric response of progressing post-SRS lesions treated with laser interstitial thermal therapy. J Neurooncol 137:57\u0026ndash;65\u003c/li\u003e\n\u003cli\u003eWen PY, Chang SM, Van den Bent MJ, et al (2017) Response Assessment in Neuro-Oncology Clinical Trials. J Clin Oncol 35:2439\u0026ndash;2449\u003c/li\u003e\n\u003cli\u003eSloan AE, Ahluwalia MS, Valerio-Pascua J, et al (2013) Results of the NeuroBlate System first-in-humans Phase I clinical trial for recurrent glioblastoma: clinical article. J Neurosurg 118:1202\u0026ndash;1219\u003c/li\u003e\n\u003cli\u003eLoi M, Caini S, Scoccianti S, et al (2020) Stereotactic reirradiation for local failure of brain metastases following previous radiosurgery: Systematic review and meta-analysis. Crit Rev Oncol Hematol 153:103043\u003c/li\u003e\n\u003cli\u003eKim AH, Tatter S, Rao G, et al (2020) Laser Ablation of Abnormal Neurological Tissue Using Robotic NeuroBlate System (LAANTERN): 12-Month Outcomes and Quality of Life After Brain Tumor Ablation. Neurosurgery 87:E338\u0026ndash;E346\u003c/li\u003e\n\u003cli\u003eHolt DE, Gill BS, Clump DA, et al (2015) Tumor bed radiosurgery following resection and prior stereotactic radiosurgery for locally persistent brain metastasis. Front Oncol 5:84\u003c/li\u003e\n\u003cli\u003eRana N, Pendyala P, Cleary RK, et al (2017) Long-term Outcomes after Salvage Stereotactic Radiosurgery (SRS) following In-Field Failure of Initial SRS for Brain Metastases. Front Oncol 7:279\u003c/li\u003e\n\u003cli\u003eDincoglan F, Sager O, Demiral S, et al (2019) Fractionated stereotactic radiosurgery for locally recurrent brain metastases after failed stereotactic radiosurgery. Indian J Cancer 56:151\u0026ndash;156\u003c/li\u003e\n\u003cli\u003eNiranjan A, Monaco E, Flickinger J, Lunsford LD (2019) Guidelines for Multiple Brain Metastases Radiosurgery. Prog Neurol Surg 34:100\u0026ndash;109\u003c/li\u003e\n\u003cli\u003eAchrol AS, Rennert RC, Anders C, et al (2019) Brain metastases. Nat Rev Dis Primers 5:5\u003c/li\u003e\n\u003cli\u003eAlattar AA, Bartek J Jr, Chiang VL, et al (2019) Stereotactic Laser Ablation as Treatment of Brain Metastases Recurring after Stereotactic Radiosurgery: A Systematic Literature Review. World Neurosurg 128:134\u0026ndash;142\u003c/li\u003e\n\u003cli\u003eVerma N, Cowperthwaite MC, Burnett MG, Markey MK (2013) Differentiating tumor recurrence from treatment necrosis: a review of neuro-oncologic imaging strategies. Neuro Oncol 15:515\u0026ndash;534\u003c/li\u003e\n\u003cli\u003eAlomari A, Rauch PJ, Orsaria M, et al (2014) Radiologic and histologic consequences of radiosurgery for brain tumors. J Neurooncol 117:33\u0026ndash;42\u003c/li\u003e\n\u003cli\u003eDixit KS, Kumthekar PU (2020) Optimal Management of Corticosteroids in Patients with Intracranial Malignancies. Curr Treat Options Oncol 21:77\u003c/li\u003e\n\u003cli\u003eRamakrishna R, Formenti S (2019) Radiosurgery and Immunotherapy in the Treatment of Brain Metastases. World Neurosurg 130:615\u0026ndash;622\u003c/li\u003e\n\u003cli\u003eKroeze SGC, Fritz C, Hoyer M, et al (2017) Toxicity of concurrent stereotactic radiotherapy and targeted therapy or immunotherapy: A systematic review. Cancer Treat Rev 53:25\u0026ndash;37\u003c/li\u003e\n\u003cli\u003eSchwabe B, Kahn T, Harth T, et al (1997) Laser-induced thermal lesions in the human brain: short- and long-term appearance on MRI. J Comput Assist Tomogr 21:818\u0026ndash;825\u003c/li\u003e\n\u003cli\u003eCamidge DR, Lee EQ, Lin NU, et al (2018) Clinical trial design for systemic agents in patients with brain metastases from solid tumours: a guideline by the Response Assessment in Neuro-Oncology Brain Metastases working group. Lancet Oncol 19:e20\u0026ndash;e32\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eTABLE 1. Patient demographics and lesion characteristics\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" width=\"876\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003ePatient\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"56\"\u003e\n\u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e\u003cstrong\u003ePre-SLA KPS\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e\u003cstrong\u003ePre-SLA corticosteroid\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary Tumor\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e\u003cstrong\u003eLocation\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e\u003cstrong\u003eLesion volume (cm\u003csup\u003e3\u003c/sup\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u003cstrong\u003ePrior WBRT\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e\u003cstrong\u003ePrior SRS dose (Gy)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"56\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003eY\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eColon\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003eL thalamus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e3.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e58\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"56\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003eY\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eMelanoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003eL thalamus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e4.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e54\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"56\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003eY\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eBreast\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003eR thalamus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e5.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e4*\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"56\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003eY\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eBreast\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003eL frontal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e3.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e4*\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"56\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003eY\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eBreast\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003eL parietal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e4.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e73\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"56\"\u003e\n\u003cp\u003eM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003eY\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eLung\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003eR temporal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e4.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e69\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"56\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003eY\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eOvarian\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003eL cerebellar\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e15.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e73\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"56\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e70\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003eY\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eUrothelial\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003eL peri-atrial\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e35\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e53\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"56\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003eY\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eEsophageal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003eL temporal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e4.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e9\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e34\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"56\"\u003e\n\u003cp\u003eM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e70\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003eY\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eMelanoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003eRperi-atrial\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e34.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e10\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e66\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"56\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003eY\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eBreast\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003eL parietal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e27.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e11\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e66\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"56\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003eY\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eLung\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003eL cingulate\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e25.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eY\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e12\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e58\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"56\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003eY\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eSCC larynx\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003eR parietal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e3.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e13\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e74\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"56\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003eY\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eLung\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003eL parietal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e14\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e64\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"56\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003eY\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eBreast\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003eL parietal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e5.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e15\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e57\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"56\"\u003e\n\u003cp\u003eM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003eY\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eColon\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003eL cerebellar\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e16\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e56\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"56\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003eY\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eLung\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003eL parietal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e21\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e17\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"56\"\u003e\n\u003cp\u003eM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003eY\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eEsophageal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003eR parietal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e8.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e18\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e56\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"56\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003eY\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eUndifferentiated\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003eL temporal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e3.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e19\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e69\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"56\"\u003e\n\u003cp\u003eM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003eY\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eLung\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003eL parietal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e4.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e20\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e69\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"56\"\u003e\n\u003cp\u003eM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003eY\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eLung\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003eL occipital\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e: female. \u003cstrong\u003eKPS\u003c/strong\u003e: Karnofsky performance score prior to SLA. \u003cstrong\u003eL\u003c/strong\u003e: left. \u003cstrong\u003eM\u003c/strong\u003e: male. \u003cstrong\u003eN\u003c/strong\u003e: no. \u003cstrong\u003eR\u003c/strong\u003e: right. \u003cstrong\u003eSCC\u003c/strong\u003e: squamous cell carcinoma.\u003cstrong\u003eWBRT\u003c/strong\u003e: prior whole brain radiation therapy. \u003cstrong\u003eY\u003c/strong\u003e: yes.\u003c/p\u003e\n\u003cp\u003e*Two lesions treated in the same patient.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eTable 2. Stereotactic Laser Ablation and consolidation stereotactic radiosurgery (SLA/cSRS)\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003ePatient\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e\u003cstrong\u003e%oflesion ablated\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"210\"\u003e\n\u003cp\u003e\u003cstrong\u003eDays to cSRS\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003e\u003cstrong\u003eLaser system\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u003cstrong\u003ecSRS\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e\u003cstrong\u003ecSRS modality\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e77.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"210\"\u003e\n\u003cp\u003e30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eMonteris\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e5 Gy x 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eLINAC\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e74.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"210\"\u003e\n\u003cp\u003e23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eMonteris\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e5 Gy x 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eLINAC\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e98.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"210\"\u003e\n\u003cp\u003e23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eMonteris\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e5 Gy x 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eLINAC\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e4*\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e92.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"210\"\u003e\n\u003cp\u003e30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eMonteris\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e5 Gy x 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eLINAC\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e4*\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"210\"\u003e\n\u003cp\u003e37\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eMonteris\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e5 Gy x 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eLINAC\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"210\"\u003e\n\u003cp\u003e23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eMonteris\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e5 Gy x 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eLINAC\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"210\"\u003e\n\u003cp\u003e26\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eVisualase\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e5 Gy x 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eGK\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e73\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"210\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eVisualase\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e5 Gy x 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eGK\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"210\"\u003e\n\u003cp\u003e19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eVisualase\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e5 Gy x 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eGK\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e9\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e97\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"210\"\u003e\n\u003cp\u003e30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eVisualase\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e5 Gy x 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eGK\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e10\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"210\"\u003e\n\u003cp\u003e40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eVisualase\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e5 Gy x 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eGK\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e11\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"210\"\u003e\n\u003cp\u003e27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eVisualase\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e5 Gy x 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eGK\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e12\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"210\"\u003e\n\u003cp\u003e35\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eMonteris\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e5 Gy x 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eGK\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e13\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e92.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"210\"\u003e\n\u003cp\u003e27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eMonteris\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e6 Gy x 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eGK\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e14\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e97.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"210\"\u003e\n\u003cp\u003e24\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eMonteris\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e5 Gy x 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eGK\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e15\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e99.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"210\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eMonteris\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e5 Gy x 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eGK\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e16\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"210\"\u003e\n\u003cp\u003e25\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eMonteris\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e6 Gy x 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eGK\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e17\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e99.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"210\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eMonteris\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e5 Gy x 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eGK\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e18\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"210\"\u003e\n\u003cp\u003e73\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eMonteris\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e5 Gy x 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eGK\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e19\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"210\"\u003e\n\u003cp\u003e24\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eMonteris\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e5 Gy x 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eGK\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e20\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e98\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"210\"\u003e\n\u003cp\u003e36\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eMonteris\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e5 Gy x 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eGK\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003ecSRS\u003c/strong\u003e: consolidation stereotactic radiosurgery (dose x fractionation). \u003cstrong\u003eDays to cSRS\u003c/strong\u003e: days between stereotactic laser ablation and cSRS.\u003cstrong\u003eGy\u003c/strong\u003e: Gray. GK: Gamma Knife. \u003cstrong\u003eLINAC\u003c/strong\u003e: linear accelerator. \u003cstrong\u003eSLA\u003c/strong\u003e: stereotactic laser ablation.\u003cstrong\u003e% lesion ablated\u003c/strong\u003e: Percentage of contrast enhancing region of BMRS covered by blue contour line (Monteris) or orange pixel (Visualase).\u003c/p\u003e\n\u003cp\u003e*: two lesions treated in the same patient.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eTable 3. Clinical outcomes \u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" width=\"959\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u003cstrong\u003ePatient\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u003cstrong\u003ePost-SLA deficit\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u003cstrong\u003ePost- SLA KPS\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e\u003cstrong\u003ePost-cSRS KPS\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e\u003cstrong\u003eReadmission\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003e\u003cstrong\u003eLC\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e\u003cstrong\u003eSteroid (6 mo)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e\u003cstrong\u003eSteroid (12 mo)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e\u003cstrong\u003eFLAIR (6 mo)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e\u003cstrong\u003eFLAIR (12 mo)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u003cstrong\u003e4*\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u003cstrong\u003e4*\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eSeizure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eYes**\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u003cstrong\u003e9\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e70\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e70\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u003cstrong\u003e10\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u003cstrong\u003e11\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eHA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u003cstrong\u003e12\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e70\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e70\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eYes**\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u003cstrong\u003e13\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eYes**\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u003cstrong\u003e14\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e70\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e70\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u003cstrong\u003e15\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eYes**\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u003cstrong\u003e16\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eYes**\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u003cstrong\u003e17\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u003cstrong\u003e18\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u003cstrong\u003e19\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u003cstrong\u003e20\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003ecSRS\u003c/strong\u003e: consolidation SRS. \u003cstrong\u003eFLAIR\u003c/strong\u003e: fluid attenuated inversion recovery.\u003cstrong\u003eFLAIR (6 m)\u003c/strong\u003e: Expansion of FLAIR volume 6 months after cSRS (compared to FLAIR volume at the time of BMRS diagnosis). \u003cstrong\u003eFLAIR (12 m)\u003c/strong\u003e: Expansion of FLAIR volume 12 months after cSRS (compared to FLAIR volume at the time of BMRS diagnosis).\u003cstrong\u003eLC\u003c/strong\u003e: local control. \u003cstrong\u003eKPS\u003c/strong\u003e: Karnofsky performance score. \u003cstrong\u003eMo\u003c/strong\u003e: months.\u003cstrong\u003ePost-SLA deficit\u003c/strong\u003e: post-SLA neurological deficit. \u003cstrong\u003ePost-SLA KPS\u003c/strong\u003e: KPS on day post-SLA treatment. \u003cstrong\u003ePost-cSRS KPS\u003c/strong\u003e: KPS one-month post-cSRS. \u003cstrong\u003eReadmission\u003c/strong\u003e: cause of 30-day readmission. \u003cstrong\u003eSLA\u003c/strong\u003e: stereotactic laser ablation. \u003cstrong\u003eSteroid (6 m)\u003c/strong\u003e: corticosteroid treatment 6 months after cSRS. \u003cstrong\u003eSteroid (12 m)\u003c/strong\u003e: corticosteroid treatment 12 months after cSRS. \u003cstrong\u003eSRS\u003c/strong\u003e: stereotactic radiosurgery.\u003c/p\u003e\n\u003cp\u003e*: two lesions treated in the same patient.\u003c/p\u003e\n\u003cp\u003e**: corticosteroid was used to treat symptoms related to other brain metastases and unrelated to the SLA/cSRS treated BMRS.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eTable 4. Outcomes of SLA and repeat radiosurgery monotherapy\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"954\"\u003e\n\u003cp\u003e\u003cstrong\u003eA.\u0026nbsp; SLA\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e\u003cstrong\u003eReference\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e\u003cstrong\u003eNumber of patients\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"538\"\u003e\n\u003cp\u003e\u003cstrong\u003eLocal control\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003eAli et al. 2016 [13]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"538\"\u003e\n\u003cp\u003e61% at 4.6 months\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003eAhluwalia et al. 2018 [14]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"538\"\u003e\n\u003cp\u003e74% at 3 months\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003eBastos et al. 2020 [15]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e61\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"538\"\u003e\n\u003cp\u003e69.6% at 12 months\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003ctable style=\"width: 976.46px;\" border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"width: 928.46px; height: 35px;\" colspan=\"7\"\u003e\n\u003cp\u003e\u003cstrong\u003eB. Repeat SRS\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 37px;\"\u003e\n\u003ctd style=\"width: 180px; height: 37px;\"\u003e\n\u003cp\u003e\u003cstrong\u003eReference\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px; height: 37px;\"\u003e\n\u003cp\u003e\u003cstrong\u003e# of patients\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px; height: 37px;\"\u003e\n\u003cp\u003e\u003cstrong\u003e# of BMRS \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 149px; height: 37px;\"\u003e\n\u003cp\u003e\u003cstrong\u003eMedian SRS dose (Gy)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 155px; height: 37px;\"\u003e\n\u003cp\u003e\u003cstrong\u003efractions of SRS\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90px; height: 37px;\"\u003e\n\u003cp\u003e\u003cstrong\u003eLC\u003csub\u003e12\u003c/sub\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 164.46px; height: 37px;\"\u003e\n\u003cp\u003e\u003cstrong\u003eAdverse radiation effect\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"width: 180px; height: 35px;\"\u003e\n\u003cp\u003eHolt et al. 2015 [30]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px; height: 35px;\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px; height: 35px;\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 149px; height: 35px;\"\u003e\n\u003cp\u003e21\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 155px; height: 35px;\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90px; height: 35px;\"\u003e\n\u003cp\u003e75%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 164.46px; height: 35px;\"\u003e\n\u003cp\u003e13%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"width: 180px; height: 35px;\"\u003e\n\u003cp\u003eMinniti et al. 2016 [10]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px; height: 35px;\"\u003e\n\u003cp\u003e43\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px; height: 35px;\"\u003e\n\u003cp\u003e43\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 149px; height: 35px;\"\u003e\n\u003cp\u003e21\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 155px; height: 35px;\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90px; height: 35px;\"\u003e\n\u003cp\u003e70%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 164.46px; height: 35px;\"\u003e\n\u003cp\u003e19%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35.8266px;\"\u003e\n\u003ctd style=\"width: 180px; height: 35.8266px;\"\u003e\n\u003cp\u003eRana et al. 2017 [31]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px; height: 35.8266px;\"\u003e\n\u003cp\u003e32\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px; height: 35.8266px;\"\u003e\n\u003cp\u003e32\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 149px; height: 35.8266px;\"\u003e\n\u003cp\u003e26.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 155px; height: 35.8266px;\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90px; height: 35.8266px;\"\u003e\n\u003cp\u003e88%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 164.46px; height: 35.8266px;\"\u003e\n\u003cp\u003e19%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"width: 180px; height: 35px;\"\u003e\n\u003cp\u003eDincoglan et al. 2019 [32]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px; height: 35px;\"\u003e\n\u003cp\u003e30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px; height: 35px;\"\u003e\n\u003cp\u003e30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 149px; height: 35px;\"\u003e\n\u003cp\u003e21\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 155px; height: 35px;\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90px; height: 35px;\"\u003e\n\u003cp\u003e835\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 164.46px; height: 35px;\"\u003e\n\u003cp\u003e13%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eA\u003c/strong\u003e: Studies reporting stereotactic laser ablation as monotherapy for the treatment of brain metastasis that recurred locally afterradiosurgery (BMRS). \u003cstrong\u003eB\u003c/strong\u003e: Studies reporting repeat radiosurgery as monotherapy for the treatment of BMRS.\u003cstrong\u003eSRS\u003c/strong\u003e: stereotactic radiosurgery. \u003cstrong\u003eLC\u003csub\u003e12\u003c/sub\u003e\u003c/strong\u003e: local control at 12-months follow-up.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-neuro-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"neon","sideBox":"Learn more about [Journal of Neuro-Oncology](https://www.springer.com/journal/11060)","snPcode":"11060","submissionUrl":"https://submission.nature.com/new-submission/11060/3","title":"Journal of Neuro-Oncology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Brain metastasis (BM), Stereotactic laser ablation (SLA), laser interstitial thermal therapy (LITT), stereotactic radiosurgery (SRS)","lastPublishedDoi":"10.21203/rs.3.rs-794328/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-794328/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eIntroduction\u003c/u\u003e:\u003c/strong\u003e The optimal treatment paradigm for brain metastasis that recurs locally after initial radiosurgery (BMRS) remains an area of active investigation.\u0026nbsp;Here, we report outcomes for patients with BMRS treated with stereotactic laser ablation (SLA, also known as laser interstitial thermal therapy, LITT)followed by consolidation radiosurgery (cSRS). \u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cu\u003eMethods\u003c/u\u003e:\u003c/strong\u003e Clinical outcome of 20 patients with 21histologically confirmed BMRS treated with SLA followed by consolidation SRS and \u0026gt;6 months follow-up were collected retrospectively across three participating institutions. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cu\u003eResults\u003c/u\u003e: \u003c/strong\u003eConsolidation SRS (5 Gy x 5 or 6 Gy x 5) wascarried out 16-73 days (median of 26 days) post-SLA of BMRS. There were no new neurological deficits after SLA/cSRS. While 3/21 (14.3%) patients suffered temporary Karnofsky Performance Score (KPS) decline after SLA, no KPS declines was observed after cSRS. There were no 30-day mortalities or wound complications. Two patients required re-admission within 30 days of cSRS (severe headache that resolved with steroid therapy (n=1) and new onset seizure (n=1)).\u0026nbsp;With a median follow-up of 228 days (range: 178-1367 days), the local control rate at 6 and 12 months (LC\u003csub\u003e6\u003c/sub\u003e, LC\u003csub\u003e12\u003c/sub\u003e) was 100%. All showed diminished FLAIR volume surrounding the SLA/cSRS treated BMRS at the six-month follow-up; none of the patients required steroid for symptoms attributable to these BMRS.\u0026nbsp;These results compare favorably to the available literature for repeat SRS or SLA-only treatment of BMRS.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cu\u003eConclusions\u003c/u\u003e:\u003c/strong\u003e This multi-institutional experience supports further investigations of SLA/cSRS as a treatment strategyfor BMRS.\u003c/p\u003e","manuscriptTitle":"Stereotactic Laser Ablation (SLA) Followed by Consolidation Stereotactic Radiosurgery (cSRS) as Treatment for Brain Metastasis that Recurred Locally After Initial Radiosurgery (BMRS): A Multi-Institutional Experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-08-11 21:26:14","doi":"10.21203/rs.3.rs-794328/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2021-08-09T11:40:33+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-08-09T11:21:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-08-09T09:18:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Neuro-Oncology","date":"2021-08-08T09:21:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-neuro-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"neon","sideBox":"Learn more about [Journal of Neuro-Oncology](https://www.springer.com/journal/11060)","snPcode":"11060","submissionUrl":"https://submission.nature.com/new-submission/11060/3","title":"Journal of Neuro-Oncology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"3aad5629-ad86-40ad-b664-88e87b5e0acc","owner":[],"postedDate":"August 11th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":6381405,"name":"Neurology"},{"id":6381406,"name":"Oncology"}],"tags":[],"updatedAt":"2021-11-03T09:47:54+00:00","versionOfRecord":[],"versionCreatedAt":"2021-08-11 21:26:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-794328","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-794328","identity":"rs-794328","version":["v1"]},"buildId":"WvIrzKhiLBfengagbw6Ux","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}