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Stereotactic radiosurgery evolved from the desire to achieve highly precise and accurate target ablation using radiation energy. Over the past 3 decades, the range of indications for stereotactic radiosurgery has expanded significantly, making it a valuable treatment option-and often a first-line approach-for various intracranial conditions, including benign and malignant brain tumors, vascular malformations, and functional disorders. This narrative review offers a comprehensive, yet not exhaustive, overview of the current evidence, technical considerations, and areas of nuance and controversy regarding these indications and dose selection. It serves as a quick reference guide for neurosurgeons and radiation oncologists working in this field. In addition, tables are included that detail the indications, expected results, dose prescriptions, and anticipated outcomes, assisting clinicians in both clinical settings and procedural planning.
Primary vaginal melanoma is a rare and aggressive malignancy with limited prospective data to guide optimal management, particularly in unresectable disease. This report describes a 40-year-old woman with unresectable, locally progressive primary vaginal melanoma refractory to first-line combination immune checkpoint inhibition. She was treated with a dose-escalated, multimodality radiotherapy approach incorporating high-dose-rate interstitial brachytherapy to the primary tumor and stereotactic body radiotherapy with simultaneous integrated boost to nodal disease. Treatment was well tolerated and resulted in a complete metabolic and radiographic response at one year. This case highlights the role of integrated, hypofractionated radiotherapy strategies in achieving durable locoregional control in patients with progressive disease despite systemic therapy.
To compare the clinical efficacy between total en bloc spondylectomy (TES) and separation surgery combined with stereotactic body radiotherapy (SSRS) in patients with isolated spinal metastases secondary to NSCLC. A total of 85 NSCLC patients diagnosed with isolated spinal metastases were enrolled in this retrospective analysis. All patients received treatment between June 2018 and April 2022, among whom 25 patients underwent TES and the remaining 60 patients were managed with SSRS. Evaluated endpoints included local tumor control, PFS, OS, postoperative complications, and quality of life assessed via the SOSGOQ scale. TES yielded superior local tumor control and significantly prolonged PFS relative to SSRS. Nevertheless, the TES group presented larger intraoperative blood loss and a higher postoperative complication incidence. Specifically, cerebrospinal fluid leakage occurred in 20% of TES patients and pleural rupture in 12%, whereas both complications only accounted for 3.3% in the SSRS cohort. No significant intergroup difference was observed in OS. TES provides superior local tumor control and extended PFS for NSCLC patients with isolated spinal metastases, accompanied by increased intraoperative blood loss and higher complication risks. OS remains comparable between the two therapeutic modalities. Both approaches effectively improve patients' postoperative quality of life. These outcomes highlight the necessity of multidisciplinary collaborative decision-making to individualize and optimize therapeutic strategies for this clinical population.
Liver metastases are common in several malignancies, with only 15-20% of patients eligible for surgical resection. For non-surgical candidates, stereotactic body radiation therapy (SBRT) is an effective alternative with acceptable local control (LC) rates. Higher biologically effective doses (BED10 > 100 Gy10) are associated with improved LC, and single-fraction ultra-high dose SBRT (35-40 Gy) has demonstrated excellent LC with minimal toxicity. MR-guided adaptive SBRT enhances precision and may optimizing single-fraction SBRT for liver metastases. ULTRAS is a multi-center, phase III randomized trial evaluating whether ultra-high dose MR-guided single-fraction SBRT (38 Gy, BED10 ≈ 180 Gy10) improves LC of liver oligometastases/oligoprogression compared to high-dose MR-guided single-fraction SBRT (27 Gy, BED10 ≈ 100 Gy10). Primary endpoint is LC of treated intrahepatic target lesion(s). Secondary endpoints include overall survival (OS), progression-free survival (PFS), intrahepatic and extrahepatic progression, toxicity (CTCAE v5.0 and PRO-CTCAE v1.0), and quality of life (QOL) (EORTC QLQ-C15-PAL, EORTC QLQ-LM21). Patients will be randomized 1:1 to receive either 27 Gy or 38 Gy, stratified by primary tumor site/histology, lesion characteristics, and prior systemic therapy. A total of 114 patients (57 per arm) will be enrolled over three years, with two years of follow-up. Assessments at predefined intervals will monitor response and toxicity. LC will be analyzed using cumulative incidence function. Widespread and intrahepatic progression will be assessed using Fine & Gray regression; OS and PFS via Cox models; toxicity and QOL via Chi-squared test and mixed-effects model. The ULTRAS trial obtained ethical approval from the University Health Network and will follow ICMJE reporting standards. ClinicalTrials.gov ID: NCT06362395.
Patients with germ cell tumors (GCT) relapsing with brain metastases (BM) can achieve durable control after multimodal salvage therapy, typically including radiotherapy (RT) and chemotherapy (CT). However, minimal data are available to inform the optimal integration of RT and CT or the appropriateness of stereotactic radiosurgery (SRS) as an alternative to whole brain radiotherapy (WBRT). This study describes outcomes after RT for BM relapse of GCT, focusing on multimodal approaches and outcomes of SRS. Patients with BM relapse of GCT treated with RT between 2005 and 2023 were included. Multimodal approaches included: RT without CT (Group B1), RT with conventional-dose CT (Group B2), RT with high-dose CT (Group B3), and RT for progressing BM initially treated with CT alone (Group B4). RT approaches included SRS and WBRT. Overall survival (OS) after RT was evaluated with the Kaplan-Meier method and Cox proportional hazards model. Time from RT to intracranial progression (IP) was evaluated using cumulative incidence estimation with Gray's test and the Fine-Gray subdistribution hazard model, with death as a competing risk. Sixty male patients were included. Groups B1-B4 included 20, 17, 13, and 10 patients, respectively. WBRT and SRS subgroups included 33 and 27 patients, respectively. Four-year OS and IP were 39% and 44%, respectively, and were not significantly associated with Groups B1-B4, nor the WBRT and SRS subgroups. SRS to a solitary BM, compared with multiple BM, was associated with superior OS (HR 0.21, p = 0.01) and IP (HR 0.27, p = 0.02). Among patients with a solitary BM, SRS and WBRT yielded similar rates of IP (p = 0.9). Patients with GCT and BM relapse can achieve long-term survival and intracranial control with various multimodal strategies incorporating RT and CT. SRS may be a suitable option for solitary GCT BM, given equivalent intracranial control to WBRT.
Stereotactic body radiotherapy (SBRT), most commonly delivered in 5 fractions, is an established treatment option for patients with localized prostate cancer. While efforts to further reduce treatment to fewer than 5 fractions are ongoing, the efficacy and tolerability of single high-dose SBRT remain to be established. To determine in men with localized prostate cancer whether a single-fraction SBRT can be a valid treatment option in terms of biochemical disease control and safety. This multicenter, single-arm, prospective, phase 1/2 nonrandomized clinical trial included men with localized prostate cancer at low or intermediate risk, with International Society of Urological Pathology grade group 1 or 2, and without significant tumor in the transitional zone. Participants were recruited between 2017 and 2022 in 5 academic centers in Europe and the US. Data were analyzed between February and May 2026. Participants were treated with a 19-Gy single-fraction prostate SBRT with urethra-sparing and intrafraction motion control. The primary end point was biochemical relapse-free survival (bRFS) at 3 years (expected value of 96% included in the 95% CI). Secondary end points included occurrence of genitourinary (GU), gastrointestinal (GI), and sexual adverse events (AEs) and quality of life (QOL) assessment. Among the 45 patients recruited (median age, 72 [range, 60-82] years), 43 were treated per protocol. After a median follow-up of 55.3 (IQR, 49.9-60.7) months, the estimated 3-year bRFS was 92.9% (95% CI, 85.4%-100%), meeting the primary end point. At 3 years, grade 2 GU and GI AEs were observed in 4 (9.8%) and 2 (4.9%) participants, respectively, with only a grade-3 proctitis observed in 1 patient at month 12. Grade 2 or higher erectile dysfunction increased from 9 of 42 patients (21.4%) at baseline to 15 of 39 (38.4%) at 3 years. A significant minimally clinically important change in Expanded Prostate Cancer Index Composite scores was observed in 6 (14%) and 12 (28%) participants for GU and sexual scores, respectively. The impact in GI bother scores was minimal. In this multicenter phase 1/2 trial, a single-fraction 19-Gy urethra-sparing SBRT met the primary end point, achieving a 3-year bRFS of 92.9%, with grade 2 GU and GI AEs remaining below 10% and 5%, respectively, at 3 years. Longer follow-up is warranted to assess long-term disease control. ClinicalTrials.gov Identifier: NCT03294889.
This study compared stereotactic ablative body radiotherapy (SABR) and radiofrequency ablation (RFA) in patients with biopsy-proven stage I renal cell carcinoma (RCC), focusing on oncologic outcomes and renal function outcomes. Patients with stage I RCC treated with CyberKnife-based SABR or percutaneous RFA between 2009 and 2024 were retrospectively analyzed. Renal function was assessed using serial changes in estimated glomerular filtration rate (eGFR). Inverse probability of treatment weighting (IPTW) was applied to adjust for baseline imbalances. With a median follow-up of 46.3 months, 123 patients (SABR, n = 54; RFA, n = 69) were analyzed. Patients treated with SABR were significantly older (p = 0.002), and had larger tumors (p < 0.001), lower baseline eGFR (p = 0.002), and tumors more frequently located anteriorly (p = 0.008) and in close proximity to the renal sinus (p = 0.012). After IPTW, SABR demonstrated oncologic outcomes comparable to RFA, with 3-year freedom from local recurrence (98.8% vs. 91.6%; p = 0.733), disease-free survival (78.5% vs. 79.3%; p = 0.965), and overall survival (82.4% vs. 87.9%; p = 0.724). The annual rate of eGFR decline was similar between groups (-2.1 vs. -1.3 mL/min/1.73 m2; p = 0.364). Sustained eGFR < 15 mL/min/1.73 m2 or dialysis occurred in 2 and 3 patients in the SABR and RFA groups, respectively. Except for one grade 3 bleeding event related to fiducial marker insertion in the SABR group, no grade ≥ 3 non-renal toxicities were observed. In patients with stage I RCC, SABR may be considered a local treatment option with oncologic and renal outcomes comparable to those of RFA.
Stereotactic radiosurgery (SRS) remains the standard of care for brain metastases (BM), offering effective local control with fewer neurocognitive side effects. However, distinguishing radiation necrosis (RN) from local recurrence (LR) is challenging in lesions that enlarge post-SRS. Identifying clinical and treatment-related factors associated with RN vs LR may improve decision-making. Prior smaller studies have suggested time to progression may help differentiate RN from LR; we aimed to reassess this observation and explore other factors in a larger cohort. We retrospectively analyzed patients treated with SRS for BM between 2011 and 2022 who later underwent biopsy, with or without LITT, for imaging-suspected RN vs LR. Data included demographics, clinicopathologic characteristics, SRS-treatment parameters, and biopsy results. Among the identified 145 patients with 151 progressive lesions, biopsy confirmed RN in 93 (61.6%) and LR in 58 (38.4%). A subset of lesions (n = 108) had complete dosimetric data. Median age at SRS was 62 years, with a median SRS-biopsy interval of 13 months. The median prescribed dose was 20 Gy for single-fraction and 27.5 Gy for hypofractionated regimens. Multivariable models identified age ≥65 and SRS to biopsy interval ≥9 months as predictors of RN in the full cohort. In the subset group with detailed dosimetric data, V12Gy ≥ median (4.64 cm³) additionally predicted RN and improved model fit. We identified older age, a longer SRS to biopsy interval, and higher V12Gy as predictors of RN. Our predictive models incorporate these variables and may support clinical decision-making, improve diagnostic accuracy, and optimize patient outcomes.
To assess the effects of stereotactic radiotherapy (SRT) for neovascular age related macular degeneration (AMD) beyond the two year primary outcome of the StereoTactic radiotherapy for wet Age-Related macular degeneration (STAR) trial. Randomised, double masked, sham controlled, device trial involving preplanned recall from standard care. 30 NHS hospitals in the UK. 411 participants aged at least 50 years with chronic, pretreated, active AMD. Participants received one-off 16 Gray SRT or sham SRT delivered using a robotically controlled device. After two years of monthly study visits, participants reverted to routine care, with anti-VEGF drug selection and dosing intervals based on local practice, but with masking maintained, and repeat data collection at years 3 and 4 study visits. The main efficacy outcome at year 4 was the number of anti-VEGF injections, tested for superiority (fewer injections). The other main outcome was visual acuity, tested for non-inferiority (five letter margin). Safety outcomes included adverse events, serious adverse events, and microvascular abnormalities. The same analyses were undertaken at years 2, 3, and 4. A within trial costing analysis was undertaken for participants with four years' follow-up. Of 411 participants (204 (58%) women), 274 were allocated to SRT and 137 to sham SRT. The year 4 intention-to-treat efficacy analysis included 222 (81%) participants in the SRT group and 106 (77%) in the sham SRT group. The SRT group received a mean of 19.1 (standard deviation 10.9) injections over four years versus 21.6 (11.3) with sham SRT, an adjusted decrease of 3.2 injections (95% confidence interval (CI) of difference -5.7 to -0.7). During years 3 and 4, the SRT group received a mean cumulative 8.4 injections versus 8.3 injections in the sham SRT group. The final change in visual acuity in the SRT group was 8.3 letters worse than in the sham group (95% CI of difference -12.7 to -4.0). Adverse event rates were similar between groups, but reading centre-detected microvascular abnormalities occurred in 126/218 SRT treated eyes (58%) and 16/102 (16%) sham SRT treated eyes. Although the overall reduction in intravitreal therapy was maintained to year 4, the inferior vision in SRT treated eyes effectively reversed the conclusions of the year 2 primary outcome analysis and no longer supports the use of SRT to treat neovascular AMD. Including standard care, masked, extended follow-up within a clinical trial may provide useful clinical insight. ClinicalTrials.gov NCT02243878.
Stereotactic radiosurgery (SRS) is an established, minimally invasive treatment for vestibular schwannoma (VS). However, tumor control rates vary, and predictors of treatment failure remain debated. This study examines whether pre-treatment tumor volume (TV) predicts SRS outcome and explores the relationship between tumor size, Paddick Conformity Index (PCI), and long-term control. We retrospectively analyzed 928 consecutive patients with solitary VS treated using Gamma Knife radiosurgery. Patients with <2 years of radiographic follow-up were excluded to avoid pseudoprogression. Tumor size was classified using the Koos system, and volumetric measurements were obtained via gadolinium-enhanced magnetic resonance imaging. Treatment failure was defined as sustained volumetric progression. Predictive performance was evaluated using receiver operating characteristic and multivariate analysis comparing TV, Koos class, and PCI. Mean follow-up was 6.4 ± 4.0 years. The overall recurrence rate was 10%, varying by Koos class (I: 4%; II: 10%; III: 13%; IV: 10%; P = .017). PCI increased with tumor size but showed reduced predictive accuracy in larger tumors (area under the curve [AUC] 0.69 for Koos I vs. 0.48 for Koos IV). TV and KOOS classification yielded comparable predictive performance (AUC 0.57 and 0.60). In a multivariate analysis, neither TV, KOOS classification, nor PCI were independent predictors of treatment failure, whereas sex remained significantly associated with progression. Pre-treatment TV is associated with radiosurgical outcome in VS. Increasing tumor size correlates with higher recurrence risk and reduced reliability of conformity indices-constituting a volume-conformity paradoxon with implications for individualized treatment planning, particularly for large tumors.
Pediatric large-volume brain arteriovenous malformations (AVMs) carry a substantial lifelong hemorrhage risk, neurological symptoms, and treatment morbidity. Single-session stereotactic radiosurgery (SRS) is often unsuitable due to constraints on dose-volume toxicity. Volume-staged SRS (VS-SRS) enables sequential dosing of large nidus volumes, potentially enhancing safety while maintaining efficacy. Evidence in children remains limited. We aimed to evaluate outcomes of VS-SRS for large AVMs in pediatric patients. A multicenter retrospective cohort was assembled from 21 centers, including patients aged younger than 21 years treated with VS-SRS for AVMs >10 cm3. Clinical and radiological end points included obliteration, hemorrhage, and permanent symptomatic radiation-induced changes (RIC). A total of 103 patients were included (median age 14 years; IQR, 12-17). The median nidus volume at first stage was 18.2 cm3 (IQR, 12.3-25.6). Median prescription dose per stage was 17 Gy (IQR, 16-18). The median clinical follow-up from the first stage was 57.5 months (IQR, 25-138). Obliteration occurred in 42 of 103 patients (40.8%), with actuarial rates of 6.9% (95% CI: 2.8-14) at 3 years and 29% (95% CI: 20-39) at 5 years. Hemorrhage occurred in 17 of 103 patients (16.5%) during follow-up, and permanent RIC was observed in 9 of 103 patients (8.7%). VS-SRS is a reasonably safe, selected option for pediatric large-volume AVMs when microsurgical or endovascular cure is not feasible or prudent. Delivering ≥17 Gy per stage while limiting each treatment volume to <15 cm3 supports durable nidus control with acceptable toxicity. VS-SRS represents a key modality in multidisciplinary management of this historically difficult-to-treat population.
To investigate whether adding stereotactic body radiotherapy (SBRT) to lenvatinib improves outcomes for patients with unresectable hepatocellular carcinoma (uHCC) and portal vein tumor thrombosis (PVTT). This retrospective cohort study enrolled 133 cases of uHCC with PVTT treated with either lenvatinib plus SBRT (n = 65) or lenvatinib alone (n = 68) between 2021 and 2023. To minimize baseline imbalances, 1:1 propensity score matching (PSM, caliper width, 0.02) was performed. The primary endpoints were overall survival (OS) and progression-free survival (PFS). Across the full study population, patients receiving lenvatinib in combination with SBRT experienced significantly longer median OS relative to those who received lenvatinib alone (24.7 vs 16.4 months; HR=0.521, 95% CI: 0.338-0.802, p = 0.003). A similar advantage was observed for PFS (13.0 vs 8.6 months; HR=0.494, 95% CI: 0.335-0.728, p < 0.0001). These findings remained consistent after PSM, with hazard ratios of 0.589 for OS and 0.540 for PFS. The objective response rate was also substantially higher in the combination arm than in the monotherapy arm (55.4% vs 30.9%, p = 0.004). Subgroup analyses revealed that the survival advantage was confined to patients with Cheng's type I-II PVTT, whereas no significant benefit was observed in those with type III-IV disease. Furthermore, salvage hepatectomy was an independent protective factor for survival in 33 cases (24.8%), with a significantly higher conversion rate in the combined treatment group (30.8%). Both treatment groups had comparable and manageable safety profiles. Lenvatinib in combination with SBRT confers meaningful advantages in both survival and tumor response over lenvatinib monotherapy in individuals with uHCC and PVTT, particularly among those with Cheng's type I-II involvement. Moreover, this multimodal approach appears to be an effective strategy for achieving tumor downstaging and enabling subsequent salvage hepatectomy.
Many surgeons have viewed hemophilia as a relative contraindication to elective cranial procedures given the risk of intracranial hemorrhage. However, there is a growing body of literature describing the successful perioperative management of hemophilia patients, thanks to multidisciplinary collaboration between neurosurgeons, hematologists, pharmacists, and other specialists. Previous reports have described how patients with hemophilia have navigated acute neurosurgical interventions, including trauma, tumor resection, deep brain stimulation, and surgical management of epilepsy. In this illustrative case, a multidisciplinary care team managed a patient with medically refractory epilepsy and hemophilia B undergoing stereotactic electroencephalography (sEEG) monitoring. Their neurological status and hematological markers were closely monitored through an 11-day hospital stay in the epilepsy monitoring unit. The key pharmacological intervention was recombinant factor IX replacement titrated to factor IX assay levels. The patient remained clinically stable without any hemorrhagic complications. This illustrative case demonstrates a successful management strategy for sEEG placement, monitoring, and removal in a patient with hemophilia B. A multidisciplinary care strategy is integral to this model of management. https://thejns.org/doi/10.3171/CASE25892.
In locally advanced hepatocellular carcinoma (HCC), immune checkpoint inhibitors (ICI) are the frontline regimen, but the benefit of stereotactic body radiation (SBRT) in combination is unclear. Given randomized evidence for survival benefit with SBRT plus sorafenib, we performed a systematic review and meta-analysis to assess whether adding SBRT improves survival and response outcomes with acceptable toxicity. Per PRISMA guidelines, we reviewed studies published from 2020 onward evaluating adults with intermediate or advanced HCC (BCLC B/C) treated with SBRT plus ICI. Eligible studies included phase II-III RCTs, prospective cohorts, prospective single-arm studies, and retrospective comparative cohorts (≥20 patients with confounding adjustment). Primary outcomes were overall survival (OS) and progression-free survival (PFS). Secondary endpoints included objective response rate (ORR), disease control rate (DCR), and grade 3+ toxicity. A single-arm meta-analysis was performed using the REML method; logit transformation was applied for proportions, and heterogeneity was assessed through I2 and Q-test. Of 1120 screened studies, 6 (258 patients) met the inclusion criteria. Pooled median OS was 22.7 months (95% CI: 17.4-29.5; I2=68.5%). Pooled median PFS was 7.9 months (95% CI: 5.6-11.2; I2=92.1%). DCR was 93.4% (95% CI: 56.5-99.4%) and ORR was 56.3% (95% CI: 38-73%). Grade ≥3 toxicity occurred in 17.5% of patients (95% CI: 12.9-23.3%; I2=0%). SBRT combined with ICI demonstrates encouraging survival and response outcomes with manageable toxicity in unresectable HCC. Prospective randomized trials are needed to confirm efficacy and define optimal treatment algorithms.
Stereotactic body radiotherapy (SBRT) is increasingly combined with targeted and immune therapies in oligometastatic (OMD) and oligoprogressive (OprogD) non-small cell lung cancer (NSCLC). The literature is expanding but heterogeneous, obscuring the strength of evidence across different clinical scenarios. This study aimed to provide clinicians with a structured synthesis of recent studies evaluating SBRT combined with systemic therapy in OMD and OprogD NSCLC. We performed an evidence-mapping synthesis of clinical studies published between 2021-2025 assessing SBRT with systemic therapy in OMD and OprogD NSCLC. Outcomes included progression-free survival (PFS), overall survival (OS), 1-year local control (LC), biologically effective dose (BED₁₀), and grade ≥3 radiotherapy-related toxicity. Studies were categorized by disease state and systemic therapy type. Results were visualized using heatmaps, lollipop plots, and bubble charts. Historical benchmarks were included for context. Fifteen studies (5 randomized/prospective and 10 retrospective) were identified. SBRT combined with tyrosine kinase inhibitors (TKIs) in EGFR-mutant NSCLC yielded superior outcomes (PFS 15.0-29.9 months (mo), OS 25.5-59.6 mo), while immune checkpoint inhibitor (ICI) combinations showed favorable survival (PFS 18-27 mo, OS 30-72 mo). Dual-ICI regimens increased toxicity in central thoracic lesions. Best OS correlated with favorable tumor biology rather than treatment timing. BED₁₀ ≥100 Gy achieved LC >90%, with severe SBRT‑related toxicity uncommon (0-7.4%) except in dual‑ICI cohorts. In OprogD, SBRT extended systemic therapy benefit via PFS-OS dissociation and delayed treatment change. SBRT combined with systemic therapy demonstrates encouraging survival and LC with acceptable toxicity. in OMD/OprogD NSCLC. Longest survival correlates more strongly with favorable tumor biology than treatment timing, supporting biomarker-driven patient selection. Future randomized trials should validate these patterns and establish precision-based treatment algorithms.
To assess the clinical feasibility and setup accuracy of using open-face masks in combination with the AlignRT® InBore surface-guided radiation therapy (SGRT) system on the Halcyon™ for intracranial stereotactic radiotherapy (SRT), in the absence of a six degrees-of-freedom (6DoF) couch. A total of 150 treatment fractions for single brain lesions > 1 cm, across four institutions within the same healthcare organization were retrospectively and prospectively analyzed while splitting patients into four groups: closed-face masks without SGRT on Halcyon™ (G1), closed-face masks with SGRT on Halcyon (G2), open-face mask with SGRT on Halcyon (G3), and open-face mask with SGRT on TrueBeam™ with 6DoF couch (G4). For each group, patient's positioning accuracy was assessed in terms of residual rotational errors extracted following offline rigid registration between the daily CBCTs and the planning CT performed with Eclipse. SGRT significantly reduced residual rotational errors, particularly in yaw and pitch. The use of open-face masks combined with SGRT on Halcyon™ achieved rotational errors (yaw: 0.3 ± 0.3°, pitch: 0.5 ± 0.5°, roll: 0.4 ± 0.3°) approaching those observed with a TrueBeam™ and a 6DoF couch (0.2 ± 0.3° in yaw - p = 0.059, 0.3 ± 0.5° in pitch - p = 0.004, and 0.2 ± 0.3° in roll - p = 0.002). This study demonstrates the feasibility and clinically acceptable dosimetry of SRT on Halcyon™ when combining open-face masks with the AlignRT® InBore system under the evaluated clinical conditions in the absence of dedicated SRT systems.
Pituitary metastases (PM) are rare intracranial secondary tumors, most often arising from breast and lung primaries. They are clinically significant due to their association with advanced systemic malignancy and potential to cause visual, neurological, and endocrinological morbidity. Conventional therapies such as surgery and fractionated radiotherapy have limited efficacy or high morbidity. Stereotactic radiosurgery (SRS) has emerged as a minimally invasive alternative, but available evidence is limited to small, heterogeneous series. To evaluate the effectiveness and safety of SRS in patients with PM by synthesizing data on tumor control, survival outcomes, progression-free survival (PFS), and treatment-related morbidity. A systematic review and meta-analysis were performed according to PRISMA guidelines. PubMed, Embase, Scopus, Web of Science, and Cochrane Library were searched through June 2025. Eligible studies included patients with radiologically or histologically confirmed PM treated with SRS. Outcomes of interest were local tumor control, survival, PFS, radiological response, and complications, including hypopituitarism, optic neuropathy, and radiation necrosis. Data were pooled using a random-effects single-arm meta-analysis model. Six retrospective case series comprising 142 patients were included. Pooled local control following SRS was 89% (95% CI 75-96%). Six-month PFS was 97% (95% CI 83-100%). One- and two-year survival rates were 53% (95% CI 32-73%) and 40% (95% CI 15-72%), respectively. Tumor regression occurred in 34% and stable disease in 33%, while only 7% demonstrated progression. Treatment-related morbidity was low: new-onset hypopituitarism (1%), optic neuropathy (2%), and radiation necrosis (1%). SRS provides effective and durable local control of pituitary metastases with a favorable safety profile and low rates of treatment-related toxicity. Despite the poor systemic prognosis associated with PM, SRS offers meaningful intracranial disease control and symptom relief, particularly in well-selected patients with stable systemic disease. Larger prospective, standardized studies are needed to further clarify long-term endocrine and neurological outcomes.
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