Pre-operative Stereotactic Radiosurgery Followed by Resection for Brain Metastases

Patients who have a brain metastasis surgically resected have very high local rates of
disease relapse, and so the standard of care is to give either whole brain irradiation or
stereotactic radiosurgery to the resection cavity in order to prevent disease recurrence.
Stereotactic radiosurgery generally offers a more favorable side effect profile than whole
brain irradiation, but targeting a surgical resection bed can be a challenge, as post
surgical changes make it more difficult to distinguish residual tumor from scar, and much of
the dose ends up being focused on the center of the resection cavity, where there are no
substantial tumor cells.

Inclusion Criteria:

- Life expectancy of at least 12 weeks

- Karnofsky performance status of at least 50

- No contraindications to MRI scanning with intravenous contrast.

- MRI scan consistent with brain metastasis as per radiology report.

- Target lesion must measure at least 15 mm in at least one dimension, and no more than
4 cm in any dimension.

- Patients must have an extra-cranial primary tumor diagnosis.

- Patients will have no more than 4 distinct lesions within the brain. At least 1 lesion
has been recommended for surgical removal based on size, symptomology, or regional
mass effect on the brain.

- Additional lesions will each be treated with stereotactic radiosurgery.

- Patients with a documented symptomatic lesion size smaller than 3cm requiring clinical
surgical resection

- Must be aware of the neoplastic nature of his/her disease and willingly provide
written, informed consent after being informed of the procedure to be followed, the
experimental nature of the therapy, alternatives, potential benefits, side-effects,
risks and discomforts

Exclusion Criteria:

- Primary tumor histology of lymphoma, leukemia, multiple myeloma or germ cell tumor.
Moribund status or status epilepticus.

- Supratentorial mass effect with greater than 5 mm of midline shift or hydrocephalus.
Infratentorial mass effect with fourth ventricle effacement or hydrocephalus.

- More than four additional diagnosed brain metastases.

- Contraindication to general anesthesia.

- Adjacent tumor location to optic apparatus or brainstem, precluding achievement of
meaningful dose with SRS.

- Primary brain tumor.

- Contraindication to MRI scans or intravenous contrast.

- Pregnant and breast-feeding females.