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Nearly all men with metastatic hormone-sensitive prostate cancer treated with intermittent androgen deprivation therapy (ADT) experience recurrence within 6 mo of testosterone recovery. We conducted a single-arm phase 2 trial to evaluate whether addition of dual androgen receptor pathway inhibitors (ARPIs) and metastasis-directed stereotactic body radiotherapy (SBRT) to intermittent ADT improves recurrence rates for men with between one and five nonvisceral, extrapelvic metastases on prostate-specific membrane antigen positron emission tomography/computed tomography after prior radical prostatectomy. Patients received 6 mo of androgen annihilation therapy (AAT; leuprolide, abiraterone acetate plus prednisone, and apalutamide) and metastasis-directed SBRT. The primary endpoint was the percentage of patients with prostate-specific antigen (PSA)

BACKGROUND: The choice of an appropriate strategy for intracanalicular vestibular schwannoma (ICVS) is still debated. We conducted a systematic review and meta-analysis with the aim to compare treatment outcomes amongst management strategies (conservative surveillance (CS), microsurgical resection (MR), or stereotactic radiosurgery (SRS)) aiming to inform guideline recommendations on behalf of the International Stereotactic Radiosurgery Society (ISRS). METHODS: Using PRISMA guidelines, we reviewed manuscripts published between January 1990 and October 2021 referenced in PubMed or Embase. Inclusion criteria were peer-reviewed clinical studies or case series reporting a cohort of ICVS managed with CS, MR, or SRS. Primary outcome measures included tumor control, the need for additional treatment, hearing outcomes, and posttreatment neurological deficits. These were pooled using meta-analytical techniques and compared using meta-regression with random effect. RESULTS: Forty studies were included (2371 patients). The weighted pooled estimates for tumor control were 96% and 65% in SRS and CS series, respectively (P

PURPOSE: This study investigated whether Ki-67 labeling index (LI) correlated with clinical outcomes after SRS for atypical meningiomas. METHODS: This retrospective study examined 39 patients with atypical meningiomas who underwent SRS over a 10-year study period. Ki-67 LI was categorized into 3 groups: low ( 10%). Local tumor control rates (LCRs), progression-free rates (PFRs), disease-specific survival (DSS) rates, and adverse radiation-induced events (AREs) were evaluated. RESULTS: The median follow-up periods were 26 months. SRS was performed at a median prescription dose of 18 Gy for tumors with a median Ki-67 LI of 9.6%. The 3-year LCRs were 100%, 74%, and 25% in the low, intermediate, and high LI groups, respectively (p = 0.011). The 3-year PFRs were 100%, 40%, and 0% in the low, intermediate, and high LI groups (p = 0.003). The 5-year DSS rates were 100%, 89%, and 50% in the low, intermediate, and high LI groups (p = 0.019). Multivariable Cox proportional hazard analysis showed a significant correlation of high LI with lower LCR (hazard ratio [HR], 3.92; 95% confidence interval [CI] 1.18-13.04, p = 0.026), lower PFR (HR 3.80; 95% CI 1.46-9.88, p = 0.006), and shorter DSS (HR 6.55; 95% CI 1.19-35.95, p = 0.031) compared with intermediate LI. The ARE rates were minimal (8%) in the entire group. CONCLUSION: Patients with high Ki-67 LI showed significantly more tumor progression and tumor-related death. Ki-67 LI might offer valuable predictive insights for the post-SRS management of atypical meningiomas.

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OBJECTIVE: The relationship between brain metastasis resection and risk of nodular leptomeningeal disease (nLMD) is unclear. This study examined genomic alterations found in brain metastases with the aim of identifying alterations associated with postoperative nLMD in the context of clinical and treatment factors. METHODS: A retrospective, single-center study was conducted on patients who underwent resection of brain metastases between 2014 and 2022 and had clinical and genomic data available. Postoperative nLMD was the primary endpoint of interest. Targeted next-generation sequencing of > 500 oncogenes was performed in brain metastases. Cox proportional hazards analyses were performed to identify clinical features and genomic alterations associated with nLMD. RESULTS: The cohort comprised 101 patients with tumors originating from multiple cancer types. There were 15 patients with nLMD (14.9% of the cohort) with a median time from surgery to nLMD diagnosis of 8.2 months. Two supervised machine learning algorithms consistently identified CDKN2A/B codeletion and ERBB2 amplification as the top predictors associated with postoperative nLMD across all cancer types. In a multivariate Cox proportional hazards analysis including clinical factors and genomic alterations observed in the cohort, tumor volume (× 10 cm3; HR 1.2, 95% CI 1.01-1.5; p = 0.04), CDKN2A/B codeletion (HR 5.3, 95% CI 1.7-16.9; p = 0.004), and ERBB2 amplification (HR 3.9, 95% CI 1.1-14.4; p = 0.04) were associated with a decreased time to postoperative nLMD. CONCLUSIONS: In addition to increased resected tumor volume, ERBB2 amplification and CDKN2A/B deletion were independently associated with an increased risk of postoperative nLMD across multiple cancer types. Additional work is needed to determine if targeted therapy decreases this risk in the postoperative setting.

BACKGROUND: Adverse radiation effect (ARE) following stereotactic radiosurgery (SRS) for brain metastases is challenging to distinguish from tumor progression. This study characterizes the clinical implications of radiologic uncertainty (RU). METHODS: Cases reviewed retrospectively at a single-institutional, multi-disciplinary SRS Tumor Board between 2015-2022 for RU following SRS were identified. Treatment history, diagnostic or therapeutic interventions performed upon RU resolution, and development of neurologic deficits surrounding intervention were obtained from the medical record. Differences in lesion volume and maximum diameter at RU onset versus resolution were compared with paired t-tests. Median time from RU onset to resolution was estimated using the Kaplan-Meier method. Univariate and multivariate associations between clinical characteristics and time to RU resolution were assessed with Cox proportional-hazards regression. RESULTS: Among 128 lesions with RU, 23.5% had undergone ≥ 2 courses of radiation. Median maximum diameter (20 vs. 16 mm, p  6 and > 12 months in 25% and 7% of cases, respectively. Higher total EQD2 prior to RU onset (HR = 0.45, p = 0.03) and use of MR perfusion (HR = 0.56, p = 0.001) correlated with shorter time to resolution; larger volume (HR = 1.05, p = 0.006) portended longer time to resolution. Most lesions (57%) were diagnosed as ARE. Most patients (58%) underwent an intervention upon RU resolution; of these, 38% developed a neurologic deficit surrounding intervention. CONCLUSIONS: RU resolution took > 6 months in > 25% of cases. RU may lead to suboptimal outcomes and symptom burden. Improved characterization of post-SRS RU is needed.

ObjectivesImmunotherapy with immune checkpoint inhibitors has shown only limited success in the management of metastatic soft tissue sarcoma. Overall response rates (ORR) with single agent pembrolizumab were 18% and median PFS was 18 weeks on the clinical trial SARC028. One strategy to improve the responses to immunotherapy is with stereotactic body radiation therapy (SBRT), which can enhance the antitumor CD8 T cell response through the release of tumor-specific antigens, potentially priming a more diverse class of T cell receptors.MethodsThis is a phase 0, pilot prospective study taking place at a single center with 2 arms. In Arm A, patients are treated with pembrolizumab 400 mg IV infusion on day 1 of a 42-day cycle. Stereotactic body radiation therapy (SBRT) is delivered in 1-5 fractions starting on C1D15-28 and given every other day. In Arm B, patients who have started an immune checkpoint inhibitor within 60 days are treated with SBRT in addition to the current therapy.ResultsIn this study we outline testing the feasibility of adding SBRT to pembrolizumab.ConclusionThe ultimate goal of combination therapy is improved overall response, including tumors not treated with SBRT. This trial can be found registered online: NCT05488366.

Objective: In the past, brain stem was treated with surgery or placement of shunt in Pakistan. Gamma Knife surgery is currently an alternative to surgery for deep brain lesions. In the current study, we show the clinical experience of our Centre treated with Gamma Knife surgery Methods: This is a descriptive study conducted between February 2016 and October 2021. We had total 47 patients presented with focal brainstem gliomas which were selected for Gamma knife radiosurgery at the Neurospinal and Cancer Care Institute Karachi. Results: Clinical Response was observed among them 20 (42.55%) patients improved, 22(46.80%) were stable, while 05 (10.63%) got worse The mean duration of symptoms was 31.9(SD10.5± 3months). Karnofsky Performance Status (KPS) scores during Gamma knife radiosurgery were 90 in 24 patients (51%), 80 in 21 patients (44.6%), and 70 in two patients (4.2%). Four patients (10.6%) had received conventional radiotherapy before Gamma knife radiosurgery. Conclusion: Among the diverse gliomas, their peril varies not just by type but also by their intricate location within the brain. The efficacy of gamma knife radiation is excellent particularly when tackling high-grade tumors, exhibiting its prowess in both adult and pediatric cases. [ABSTRACT FROM AUTHOR]

This article from BJU International presents a case study of a 74-year-old patient with castration-resistant prostate cancer who underwent stereotactic body radiotherapy (SBRT) for 20 metastatic lesions. The patient had a complex treatment history involving various therapies before receiving SBRT, which served as a bridge therapy while awaiting 177Lu-PSMA-617 therapy. The SBRT treatment was delivered without reported side effects, resulting in a decrease in PSA levels and a partial or complete response at treated sites. The article discusses the efficacy and challenges of SBRT in treating multiple metastatic sites, highlighting the evolving landscape of prostate cancer therapy. [Extracted from the article]

To assess in patients with 1–10 brain metastases, each of which has been treated by neurosurgery or stereotactic radiosurgery, whether hippocampal sparing whole brain radiotherapy (HS-WBRT) better spares neurocognitive function (NCF) than standard WBRT. Further, to assess whether a phase III randomised trial of HS-WBRT would be feasible in the UK. A multicentre, randomised, open label phase II trial was undertaken, randomising patients to 30Gy in 10 fractions of WBRT or HS-WBRT. The primary endpoint was decline in Total recall using Hopkins Verbal Learning Test Revised (HVLT-R) at 4 months post treatment. To assess this, we aimed to recruit 84 patients over 3 years. Secondary endpoints included further measures of NCF, quality of life, duration of functional independence, local control of treated metastases, development of new metastases, disease control within the hippocampal regions, overall survival, steroid and antiepileptic medication requirements, and toxicity. The trial closed prematurely due to slower than anticipated recruitment. From April 2016 to January 2018, 23 patients were randomised. Follow up was a median of 25 months. Fifteen patients (6 WBRT, 9 HS-WBRT) were assessed for the primary endpoint; of these, 1 in each arm experienced significant decline in the 4-month HVLT-R Total recall score (p = 0.8). Patients in the HS-WBRT arm experienced less insomnia (p < 0.01) and drowsiness (p < 0.01). There were no differences in other secondary endpoints. A phase III randomised trial of HS-WBRT was shown not to be feasible at this time in the UK. As most randomised trials of HS-WBRT reported to date share common endpoints, including NCF, an individual patient data meta-analysis should be undertaken. • Changes in clinical practice away from whole brain radiotherapy necessitated early trial closure. • No significant differences in any neurocognitive outcomes were observed. • Compliance with serial neurocognitive function assessments was high. • Patients in the hippocampal sparing arm had significantly less insomnia and drowsiness. [ABSTRACT FROM AUTHOR]

The purpose of this research was to summarize the clinical and prognostic features of pineal region meningiomas, evaluate treatment strategies and long-term prognoses, and improve the management of pineal region meningiomas. We retrospectively studied the data of 37 patients who received surgical resection for pineal region meningiomas at West China Hospital of Sichuan University from 2009 to 2021. Adjuvant gamma knife radiosurgery (GKRS) was conducted according to the extent of resection (EOR). Progression-free survival (PFS), Karnofsky performance status (KPS) scores and recovery of neurological function were adopted to assess a comprehensive management strategy for pineal region meningiomas. The most common symptom was headache associated with intracranial hypertension (75.7%). The occipital transtentorial approach (40.5%) and supracerebellar infratentorial approach (29.7%) were performed in most cases. Gross total resection (GTR) was achieved in 27 patients (73.0%) and the remaining patients were treated with subtotal resection (STR) combined with postoperative GKRS. With a mean follow-up period of 87.0 months, the progression rate was 10.0%, the 5-year PFS rate was 92.9%, and the ΔKPS was 16.3. Multivariate analysis revealed that the STR + GKRS and supracerebellar infratentorial approach were beneficial to the recovery of quality of life of patients. Pineal region meningiomas are sporadic but challenging. It is necessary to select the most appropriate surgical approach, EOR, and hydrocephalus treatment strategy for patients with pineal region meningiomas. Maximal safe resection to protect neurovascular function combined with postoperative GKRS can significantly improve the quality of life of patients. [ABSTRACT FROM AUTHOR]

Breast cancer commonly metastasises to the skeleton, and stereotactic ablative body radiation therapy (SABR) is an emerging treatment for oligometastatic disease. Accurately imaging bone metastases and their response to treatment is challenging. [18F]NaF-PET has a higher sensitivity and specificity than conventional bone scans for detecting breast cancer bone metastases. In this pre-defined secondary analysis of a prospective trial, we evaluated the change in [18F]NaF uptake after SABR. Patients with oligometastatic breast cancer received a single fraction of 20 Gy to up to three bone metastases. [18F]NaF-PET was acquired before and 12 months after SABR. Pre- and post-treatment [18F] NaF-PET images were registered to the treatment planning CT. The relative change in tumour SUVmax and SUVmean was quantified. The intersection of each of the radiation therapy isodose contours with a non-tumour bone was created. The change in SUVmean in sub-volumes of non-tumour bone receiving doses of 0-20 Gy was quantified. In total, 14 patients, with 17 bone metastases, were available for analysis. A total of 15 metastases exhibited a reduction in SUVmax; the median reduction was 42% and the maximum reduction 82%. An increased absolute reduction in SUVmax was observed with higher pre-treatment SUVmax. One patient exhibited increased SUVmax after treatment, which was attributed to normal peri-tumoural bone regeneration in the context of a bone metastasis. There was a median reduction of 15%-34% for non-tumour bone in each dose level. [ABSTRACT FROM AUTHOR]

Background: Gamma Knife Radiosurgery (GKRS), a specific type of Stereotactic Radiosurgery (SRS), has developed as a significant modality in the treatment of glioblastoma, particularly in conjunction with standard chemotherapy. The goal of this study is to evaluate the efficacy of combining GKRS with surgical resection and chemotherapy in enhancing therapeutic effects for glioblastoma patients aged 55 years and older. Methods: This prospective clinical study, conducted in accordance with the STROBE guidelines, involved 49 glioblastoma patients aged 55 years and older, treated between January 2013 and January 2023. Data were collected prospectively, and strict adherence to the STUPP protocol was maintained. Only patients who conformed to the STUPP protocol were included in the analysis. Due to concerns regarding the cognitive impairment associated with conventional radiotherapy, and at the patients' request, a radiosurgery plan was offered. Radiosurgery was administered for 4–8 weeks following surgical resection. Any patients who had not received previous radiotherapy received open surgical tumor removal, followed by GKRS along with adjuvant chemotherapy. Results: In this prospective clinical study of 49 glioblastoma patients aged 55 years and older, the average lifespan post-histopathological diagnosis was established at 22.3 months (95% CI: 12.0–28.0 months). The median time before disease progression was 14.3 months (95% CI: 13.0–29.7 months). The median duration until the first recurrence after treatment was 15.2 months, with documented cases varying between 4 and 33 months. The Gamma Knife Radiosurgery (GKRS) treatment involved a median marginal recommended dose of 12.5 Gy, targeting an average volume of 5.7 cm3 (range: 1.6–39 cm3). Local recurrence occurred in 21 patients, while distant recurrence was identified in 8 patients. Within the cohort, 34 patients were subjected to further therapeutic approaches, including reoperation, a second GKRS session, the administration of bevacizumab and irinotecan, and PCV chemotherapy. A cognitive function assessment revealed that the patients treated with GKRS experienced significantly less cognitive decline compared to the historical controls, who were treated with conventional radiotherapy. The median MMSE scores declined by 1.9 points over 12 months, and the median MoCA scores declined by 2.9 points. Conclusion: This study demonstrates that Gamma Knife Radiosurgery (GKRS), when integrated with surgical resection and adjuvant chemotherapy, offers a substantial benefit for glioblastoma patients aged 55 years and older. The data reveal that GKRS not only prolongs overall survival and progression-free survival but also significantly reduces cognitive decline compared to conventional radiotherapy. These findings underscore the efficacy and safety of GKRS, advocating for its incorporation into standard treatment protocols for older glioblastoma patients. The potential of GKRS to improve patient outcomes while preserving cognitive function is compelling and warrants further research to optimize and confirm its role in glioblastoma management. [ABSTRACT FROM AUTHOR]

The article discusses a case of a pediatric supratentorial tumor with carcinoma-like epithelial features, classified as MN1-altered astroblastoma by DNA methylation profiling. The tumor exhibited a TCF3::BEND2 fusion, which is uncommon in CNS tumors. The study highlights the importance of BEND2 in tumorigenesis and suggests that further research is needed to understand the biological and clinical implications of different fusions in CNS tumors. [Extracted from the article]

Simple Summary: High-risk neuroblastoma, especially when it recurs, is challenging to treat. Since immunotherapy and target therapy have been incorporated in the treatment of these patients, tissue sample collection has a key impact on their management and prognosis. However, tissue sampling is often difficult to obtain in this population. This study investigates the use 123I-MIBG radioguided surgery, which helps surgeons access hard-to-reach areas of neuroblastoma. By using a gamma probe to detect and remove the tumor tissue, this method aims to improve tissue sampling and, ultimately, patient outcomes. The findings show that this technique was successful in all cases, allowing for complete tumor removal and enabling important molecular studies to be conducted. This approach could significantly impact how we treat and study high-risk neuroblastoma. Introduction: High-risk neuroblastoma, particularly in the relapse/refractory (R/R) setting, poses unique challenges to obtaining the representative-quality tissue that is mostly required for molecular analysis. This study explores the use of 123I-MIBG radioguided surgery to access complex locations of MIBG-positive neuroblastoma as a tool to overcome the difficulties associated with repeated surgeries in these patients. Methods: This study is a retrospective review of all patients with R/R neuroblastoma and MIBG-uptaking lesions who underwent radioguided surgery between February 2020 and 2023 at SJD Barcelona Children's Hospital. The Europrobe 3.2 gamma probe was used to identify neuroblastoma tissue in the operating room. Results: Ten patients were identified. Radioguided surgery was useful in all patients. One patient with previous multiple operations developed an entero-cutaneous fistula with posterior full recovery. Mean surgical time was 111.7 min. The gamma probe identified 100% of neuroblastoma lesions which were all completely removed (123I-MIBG-SPECT/CT negative post-surgery). Pathology and molecular studies could be successfully performed in all samples. Conclusions: 123I-MIBG radioguided surgery proved effective in obtaining viable tissue from difficult-to-access sites in high-risk relapsed neuroblastoma. [ABSTRACT FROM AUTHOR]

Simple Summary: Stereotactic body radiotherapy (SBRT) is a treatment technique that delivers higher doses of conformal radiation precisely to specific targets. SBRT is utilized for the treatment of the more common cancers such as lung, liver and prostate malignancies, both in the early stage and the oligometastatic setting. The aim of this review is to highlight the current role of SBRT for renal cell carcinoma (RCC), a disease which was previously thought to be radioresistant, particularly to conventionally fractionated radiotherapy. There is now an increasing body of literature encompassing published phase II trials, reviews and meta-analyses demonstrating the effectiveness of SBRT in both early-stage RCC (as an alternative to patients who are not surgical candidates) and within the context of metastasis-directed therapy (MDT) for patients with oligometastatic and oligoprogressive RCC. Ongoing randomized trials are also exploring the role of SBRT as a cytoreductive treatment in metastatic RCC. Renal cell carcinoma (RCC) has been increasing in incidence by around 1.5% per year for several years. However, the mortality rate has been decreasing by 1.6% per year, and this can be attributed to stage migration and improvements in treatment. One treatment modality that has emerged in recent years is stereotactic body radiotherapy (SBRT), which is an advanced radiotherapy technique that allows the delivery of high-dose radiation to the tumor while minimizing doses to the organs at risk. SBRT has developed a role in the treatment of early-stage, oligometastatic and oligoprogressive RCC. In localized disease, phase II trials and meta-analyses have shown that SBRT provides a very high probability of long-term local control with a low risk of severe late toxicity. In oligometastatic (OMD) RCC, the same level of evidence has similarly shown good local control and minimal toxicity. SBRT could also delay the necessity to start or switch systemic treatments. Medical societies have started to incorporate SBRT in their guidelines in the treatment of localized disease and OMD. A possible future role of SBRT involves cytoreduction. It is theorized that SBRT can lower tumor burden and enhance immune-related response, but it cannot be recommended until the results of the phase II trials are published. [ABSTRACT FROM AUTHOR]

Simple Summary: To examine predictors of brain necrosis (BN) in fractionated SRT for BMs, comprehensive analyses of dosimetric parameters were conducted. The normal brain volume receiving an xx Gy biological dose in 2 Gy fractions (VxxEQD2) was calculated, and collinearities were carefully excluded. Three-fraction SRT was delivered to 34 patients with 75 BMs, five-fraction SRT to 58 patients with 104 BMs, and ten-fraction SRT to 20 patients with 37 BMs depending on the target volume. The incidence of BN was also significantly higher in cases with V55EQD2 > 30 cc or V60EQD2 > 20 cc. These doses correspond to 28 or 30 Gy/5 fr and 37 or 40 Gy/10 fr, respectively. These biologically high doses may affect BN incidence. Thus, the planning target volume margin should be minimized as much as possible. Background: The objective was to explore dosimetric predictors of brain necrosis (BN) in fractionated stereotactic radiotherapy (SRT). Methods: After excluding collinearities carefully, multivariate logistic models were developed for comprehensive analyses of dosimetric predictors in patients who received first-line fractionated SRT for brain metastases (BMs). The normal brain volume receiving an xx Gy biological dose in 2 Gy fractions (VxxEQD2) was calculated from the retrieved dose–volume parameters. Results: Thirty Gy/3 fractions (fr) SRT was delivered to 34 patients with 75 BMs (median target volume, 3.2 cc), 35 Gy/5 fr to 30 patients with 57 BMs (6.4 cc), 37.5 Gy/5 fr to 28 patients with 47 BMs (20.2 cc), and 40 Gy/10 fr to 20 patients with 37 BMs (24.3 cc), according to protocols, depending on the total target volume (p < 0.001). After excluding the three-fraction groups, the incidence of symptomatic BN was significantly higher in patients with a larger V50EQD2 (adjusted odds ratio: 1.07, p < 0.02), V55EQD2 (1.08, p < 0.01), or V60EQD2 (1.09, p < 0.01) in the remaining five- and ten-fraction groups. The incidence of BN was also significantly higher in cases with V55EQD2 > 30 cc or V60EQD2 > 20 cc (p < 0.05). These doses correspond to 28 or 30 Gy/5 fr and 37 or 40 Gy/10 fr, respectively. Conclusions: In five- or ten-fraction SRT, larger V55EQD2 or V60EQD2 are BN risk predictors. These biologically high doses may affect BN incidence. Thus, the planning target volume margin should be minimized as much as possible. [ABSTRACT FROM AUTHOR]

Simple Summary: Renal cancer is the eighth most frequent cancer in Europe, and its prevalence is increasing. Surgery is the treatment of choice for localised renal cell carcinoma requiring interventional management, but less invasive treatment methods are emerging. Stereotactic body radiotherapy (SBRT) utilises precise delivery of high doses of radiation to ablate the primary cancer. In our systematic review and meta-analysis, we pooled data from available prospective trials, including 13 studies involving 308 patients. The results of the meta-analysis show that SBRT for localised renal cell carcinoma is highly effective in controlling local diseases and has low complication rates. In the second year, 97% of patients were free from local recurrence. Only 3% experienced severe adverse events, which included abdominal pain and fatigue. SBRT presents a valuable treatment for patients who require treatment but cannot undergo surgery; however, it has not been yet confirmed to be equieffective to surgery as trials directly comparing these methods are missing. Context: Surgery is the gold standard for the local treatment of primary renal cell carcinoma (RCC), but alternatives are emerging. We conducted a systematic review and meta-analysis to assess the results of prospective studies using definitive stereotactic body radiotherapy (SBRT) to treat primary localised RCC. Evidence acquisition: This review was prospectively registered in PROSPERO (CRD42023447274). We searched PubMed, Embase, Scopus, and Google Scholar for reports of prospective studies published since 2003, describing the outcomes of SBRT for localised RCC. Meta-analyses were performed for local control (LC), overall survival (OS), and rates of adverse events (AEs) using generalised linear mixed models (GLMMs). Outcomes were presented as rates with corresponding 95% confidence intervals (95% CIs). Risk-of-bias was assessed using the ROBINS-I tool. Evidence synthesis: Of the 2983 records, 13 prospective studies (n = 308) were included in the meta-analysis. The median diameter of the irradiated tumours ranged between 1.9 and 5.5 cm in individual studies. Grade ≥ 3 AEs were reported in 15 patients, and their estimated rate was 0.03 (95%CI: 0.01–0.11; n = 291). One- and two-year LC rates were 0.98 (95%CI: 0.95–0.99; n = 293) and 0.97 (95%CI: 0.93–0.99; n = 253), while one- and two-year OS rates were 0.95 (95%CI: 0.88–0.98; n = 294) and 0.86 (95%CI: 0.77–0.91; n = 224). There was no statistically significant heterogeneity, and the estimations were consistent after excluding studies at a high risk of bias in a sensitivity analysis. Major limitations include a relatively short follow-up, inhomogeneous reporting of renal function deterioration, and a lack of prospective comparative evidence. Conclusions: The short-term results suggest that SBRT is a valuable treatment method for selected inoperable patients (or those who refuse surgery) with localised RCC associated with low rates of high-grade AEs and excellent LC. However, until the long-term data from randomised controlled trials are available, surgical management remains a standard of care in operable patients. [ABSTRACT FROM AUTHOR]

Stereotactic ablative body radiotherapy (SABR) is increasingly used for early-stage lung cancer, however the impact of dose to the heart and cardiac substructures remains largely unknown. The study investigated doses received by cardiac substructures in SABR patients and impact on survival. SSBROC is an Australian multi-centre phase II prospective study of SABR for stage I non-small cell lung cancer. Patients were treated between 2013 and 2019 across 9 centres. In this secondary analysis of the dataset, a previously published and locally developed open-source hybrid deep learning cardiac substructure automatic segmentation tool was deployed on the planning CTs of 117 trial patients. Physical doses to 18 cardiac structures and EQD2 converted doses (α/β = 3) were calculated. Endpoints evaluated include pericardial effusion and overall survival. Associations between cardiac doses and survival were analysed with the Kaplan–Meier method and Cox proportional hazards models. Cardiac structures that received the highest physical mean doses were superior vena cava (22.5 Gy) and sinoatrial node (18.3 Gy). The highest physical maximum dose was received by the heart (51.7 Gy) and right atrium (45.3 Gy). Three patients developed grade 2, and one grade 3 pericardial effusion. The cohort receiving higher than median mean heart dose (MHD) had poorer survival compared to those who received below median MHD (p = 0.00004). On multivariable Cox analysis, male gender and maximum dose to ascending aorta were significant for worse survival. Patients treated with lung SABR may receive high doses to cardiac substructures. Dichotomising the patients according to median mean heart dose showed a clear difference in survival. On multivariable analyses gender and dose to ascending aorta were significant for survival, however cardiac substructure dosimetry and outcomes should be further explored in larger studies. • Eighteen cardiac structure automatic segmentation tool deployed on planning datasets. • Data from phase II multicentre trial of stereotactic lung radiotherapy. • Dichotomising patients according to mean heart dose showed a difference in survival. • Gender and maximum dose to ascending aorta were significant on multivariable analysis. [ABSTRACT FROM AUTHOR]

To present the final results of a phase I trial on stereotactic radiosurgery (SRS) delivered using volumetric modulated arc therapy (VMAT) in patients with primary or metastatic tumors in different extracranial sites. The DESTROY-2 trial, planned as a prospective dose escalation study in oligometastatic (one to five lesions) cancer patients relied on the delivery of a single high dose of radiation utilizing high-precision technology. The primary study endpoint was the definition of the maximum tolerated dose (MTD) of SRS-VMAT. The secondary objectives of the study were the evaluation of safety, efficacy, and long-term outcomes. All patients consecutively observed at our radiotherapy unit matching the inclusion criteria were enrolled. Each enrolled subject was included in a different phase I study arm, depending on the tumor site and the disease stage (lung, liver, bone, other), and sequentially assigned to a particular dose level. Two hundred twenty seven lesions in 164 consecutive patients (male/female: 97/67, median age: 68 years; range: 29–92) were treated. The main primary tumors were: prostate cancer (60 patients), colorectal cancer (47 patients), and breast cancer (39 patients). The maximum planned dose level was achieved in all study arms, and the MTD was not exceeded. 34 Gy, 32 Gy, 24 Gy, and 24 Gy were established as the single-fraction doses for treating lung, liver, bone, and other extracranial lesions, respectively. The prescribed BED 2Gy α/β:10 to the planning target volume ranged from 26.4 Gy to 149.6 Gy. Twenty-seven patients (16.5%) experienced grade 1–2 and only one grade 3 acute toxicity, which was a pulmonary one. In terms of late toxicity, we registered only 5 toxicity>G2: a G3 gastro-intestinal one, three G3 bone toxicity, and a G3 laryngeal toxicity. The overall response was available for 199 lesions: 107 complete response (53.8%), 50 partial response (25.1%), and 31 stable disease (15.6%), leading to an overall response rate of 94.5%. Progression was registered only in 11 cases (5.5%). The overall response rate in each arm ranged from 88.6% to 96.4%. The overall two-year local control, distant metastasis free survival, disease free survival, and overall survival were 81.7%, 33.0%, 25.4%, and 78.7% respectively. In conclusion, the planned doses of 34 Gy, 32 Gy, 24 Gy, and 24 Gy were successfully administered as single-fractions for the treatment of lung, liver, bone, and other extracranial lesions, respectively, in a prospective SRS dose-escalation trial. No dose-limiting toxicities were registered, and minimal acute and late toxicity were reported. New indications for SRS are currently being studied in oligoprogressive patients receiving targeted drugs or in combination with immunotherapy. The DESTROY-2 trial represents, in our opinion, a credible starting point for future modern radiosurgery trials. • One of the few prospective SRS studies exploring MTD across different clinical settings. • 34 Gy, 32 Gy, and 24 Gy single fraction were safely delivered to lung, liver, bone. • The highest dose level was reached in all the settings, not exceeding the MTD. • The toxicity profile was low with one acute and five late toxicities >G2. • High LC rates and encouraging long-term outcomes were observed. [ABSTRACT FROM AUTHOR]

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Featured Application: The conclusions of the study are pragmatic in terms of the implementation of prostate cancer radiotherapy using the CyberKnife system. (1) Background: For patients irradiated due to prostate cancer, monitoring of bladder volume (BV) is crucial for accuracy of radiation delivery and minimizing exposure to surrounding healthy tissues. Due to the limited imaging capabilities of the CyberKnife system, ultrasound imaging plays a vital role in the monitoring of bladder filling. (2) Methods: A study was carried out in 142 prostate cancer patients treated with the CyberKnife system. Bladder ultrasound (US) was performed before each RTH session to assess real BV (rBV). The double US assessment of rBV was performed by two independent operators or a single operator during 177 and 495 RTH sessions, respectively, giving, in total, 1344 BV assessments. (3) Results: The mean BV in the first and second US assessment was 214.7 mL and 218.1 mL, respectively, while the mean planning bladder volume (pBV) was 340.8 mL. A pBV was significantly higher than an rBV. The mean difference between the US and CT assessment of BV was the smallest in the 100–349 mL group and the largest in the group above 349 mL. The Passing–Bablok regression results confirmed the reliability of the ultrasound (US) measurements. (4) Conclusions: The introduction of US-based BV assessment in patients irradiated due to prostate cancer using CyberKnife seems to be a crucial element in controlling the reproducibility of the treatment plan and should be a standard procedure. The pBV should be within the range of 200–300 mL. The US examination prior to CT scanning for planning is recommended to ensure the optimal range of BV for CT. [ABSTRACT FROM AUTHOR]

Purpose: To report patient outcomes and local tumor control rates in a cohort of patients with biopsy-proven HER-2 positive breast cancer treated with stereotactic radiosurgery (SRS) for brain metastases (BM). Methods: This international, retrospective, multicenter study, included 195 female patients with 1706 SRS-treated BM. Radiologic and clinical outcomes after SRS were determined and prognostic factors identified. Results: At SRS, median patient age was 55 years [interquartile range (IQR) 47.6–62.0], and 156 (80%) patients had KPS ≥ 80. The median tumor volume was 0.1 cm3 (IQR 0.1–0.5) and the median prescription dose was 16 Gy (IQR 16–18). Local tumor control (LTC) rate was 98%, 94%, 93%, 90%, and 88% at six-, 12-, 24-, 36- and 60-months post-SRS, respectively. On multivariate analysis, tumor volume (p = < 0.001) and concurrent pertuzumab (p = 0.02) improved LTC. Overall survival (OS) rates at six-, 12-, 24-, 36-, 48-, and 60-months were 90%, 69%, 46%, 27%, 22%, and 18%, respectively. Concurrent pertuzumab improved OS (p = 0.032). In this patient subgroup, GPA scores ≥ 2.5 (p = 0.038 and p = 0.003) and rare primary tumor histologies (p = 0.01) were associated with increased and decreased OS, respectively. Asymptomatic adverse radiation events (ARE) occurred in 27 (14.0%) and symptomatic ARE in five (2.6%) patients. Invasive lobular carcinoma primary (p = 0.042) and concurrent pertuzumab (p < 0.001) conferred an increased risk for overall but not for symptomatic ARE. Conclusion: SRS affords effective LTC for selected patients with BM from HER-2 positive breast cancer. Concurrent pertuzumab improved LTC and OS but at the same time increased the risk for overall, but not symptomatic, ARE. [ABSTRACT FROM AUTHOR]

Objective: Brain arteriovenous malformations (BAVMs) represent an ongoing clinical challenge because of their complex nature. The long-term outcomes of BAVMs patients treated with stereotactic radiosurgery (SRS) alone are unclear. Methods: We conducted a retrospective analysis of 201 patients treated for BAVMs from January 2010 to December 2019. The identified predictors of obliteration or hemorrhage in the multivariate analysis were estimated by odds ratios (ORs) with 95% confidence intervals (CIs). Results: A total of 201 patients treated with gamma knife radiosurgery (GKRS) alone as the primary treatment for BAVMs were included. The mean age at GKRS treatment was 31.4 ± 1.1 years, and 61.2% of the patients were male. Multivariate logistic regression revealed that a higher radiosurgery-based AVM score (OR 1.847, 95% CI = 1.292–2.641; p = 0.001) was significantly associated with worse obliteration, and a higher margin dose significantly favored obliteration (OR 0.352, 95% CI = 0.189–0.658; p = 0.001). Multivariate analysis revealed that an increased lesion volume of 1 cm3 (OR 1.279, 95% CI = 1.023–1.600; p = 0.031) and a high margin dose (OR 0.363, 95% CI = 0.134–0.983; p = 0.046) were significant prognostic factors for post-SRS hemorrhage. Conclusions: In conclusion, our study investigated the available clinical and radiological prognostic factors for BAVMs and revealed that a higher margin dose significantly improved both the obliteration rate and nonhemorrhagic outcomes. Currently, the most appropriate candidates, Spetzler-Martin grade, and optimal radiation dose are still being defined by prospective trials. [ABSTRACT FROM AUTHOR]

Although stereotactic body radiotherapy (SBRT) is a curative treatment option for stage I non‐small cell lung cancer (NSCLC), limited data are available regarding chest wall (CW) toxicities during an extended follow‐up of over 10 years. We report an unusual case of a bone tumor‐like CW mass lesion with pathological rib fractures observed 13 years after SBRT for peripheral lung cancer. Despite the initial suspicion of radiation‐induced sarcoma, a subsequent incisional biopsy revealed no evidence of malignancy, and a definitive diagnosis of osteonecrosis was made. Thus, long‐term observation of over 10 years is required to identify late chronic complications following SBRT. [ABSTRACT FROM AUTHOR]

Introduction: Accurate prediction of tumor dynamics following Gamma Knife radiosurgery (GKRS) is critical for optimizing treatment strategies for patients with brain metastases (BMs). Traditional machine learning (ML) algorithms have been widely used for this purpose; however, recent advancements in deep learning, such as autoencoders, offer the potential to enhance predictive accuracy. This study aims to evaluate the efficacy of autoencoders compared to traditional ML models in predicting tumor progression or regression after GKRS. Objectives: The primary objective of this study is to assess whether integrating autoencoder-derived features into traditional ML models can improve their performance in predicting tumor dynamics three months post-GKRS in patients with brain metastases. Methods: This retrospective analysis utilized clinical data from 77 patients treated at the "Prof. Dr. Nicolae Oblu" Emergency Clinic Hospital-Iasi. Twelve variables, including socio-demographic, clinical, treatment, and radiosurgery-related factors, were considered. Tumor progression or regression within three months post-GKRS was the primary outcome, with 71 cases of regression and 6 cases of progression. Traditional ML models, such as Logistic Regression, Support Vector Machine (SVM), K-Nearest Neighbors (KNN), Extra Trees, Random Forest, and XGBoost, were trained and evaluated. The study further explored the impact of incorporating features derived from autoencoders, particularly focusing on the effect of compression in the bottleneck layer on model performance. Results: Traditional ML models achieved accuracy rates ranging from 0.91 (KNN) to 1.00 (Extra Trees). Integrating autoencoder-derived features generally enhanced model performance. Logistic Regression saw an accuracy increase from 0.91 to 0.94, and SVM improved from 0.85 to 0.96. XGBoost maintained consistent performance with an accuracy of 0.94 and an AUC of 0.98, regardless of the feature set used. These results demonstrate that hybrid models combining deep learning and traditional ML techniques can improve predictive accuracy. Conclusion: The study highlights the potential of hybrid models incorporating autoencoder-derived features to enhance the predictive accuracy and robustness of traditional ML models in forecasting tumor dynamics post-GKRS. These advancements could significantly contribute to personalized medicine, enabling more precise and individualized treatment planning based on refined predictive insights, ultimately improving patient outcomes. [ABSTRACT FROM AUTHOR]

Simple Summary: Although some of the novel systemic treatments, especially the group of tyrosine kinase inhibitors, have shown a durable central nervous system response, ionizing radiation remains the mainstay in the management of brain metastases (BM). Recent technological advancements have enabled the replacement of whole-brain radiotherapy with localized stereotactic radiotherapy (SRT) for treating up to 10 BM, either as a primary or combined treatment, reducing neurotoxicity and improving local control (LC). The delivered target dose and patient selection play a crucial role in enhancing treatment efficacy. However, there is still limited evidence supporting which factors most affect LC and which patients derive the greatest benefit from SRT. This retrospective single-institutional study evaluated treatment outcomes in a heterogeneous patient population treated with Linac-based SRT, with the aim of identifying potential dosimetric and clinical prognostic factors to better inform the decision-making process. Background/Objectives: To report on predictive factors in Linac-based SRT for single and multiple BM. Methods: Consecutive patients receiving either one or three fractions of single-isocenter coplanar VMAT SRT were retrospectively included. The GTV-PTV margin was 1–2 mm. The delivered target dose was estimated by recalculating the original plans on roto-translated CT according to errors recorded by post-treatment CBCT. The Kaplan–Meier method estimated local progression-free survival (LPFS), intracranial progression-free survival (IPFS), and overall survival (OS). Log-rank and Wilcoxon–Mann–Whitney tests evaluated inter-group differences, whereas Cox regression analysis assessed prognostic factors. Results: Fifty females and fifty males, with a median age of 69 years, received 107 SRTs. A total of 213 BM (range, 1–10 per treatment) with a median volume of 0.22 cc were irradiated with a median minimum BED of 59.5 Gy. The median delivered GTV D95 reduction was −0.3%. The median follow-up was 11 months. Nineteen LP events and a 1-year LC rate of 90.1% were observed. The GTV coverage did not correlate with LC, while the GTV volume was a risk factor for LP, with the 1-year rate dropping to 73% for volumes ≥ 0.88 cc. The median LPFS, IPFS, and OS were 6, 5, and 7 months, respectively. Multivariate analysis showed that patients with melanoma histology and those receiving a second or subsequent systemic therapy line had the worst outcomes, whereas patients with adenocarcinoma histology and mutations showed better results. Conclusions: The accuracy and efficacy of the Linac-based SRT approach for BM were confirmed, but the dose distribution alone failed to predict the treatment response, suggesting that other factors must be considered to maximize SRT outcomes. [ABSTRACT FROM AUTHOR]

Simple Summary: In this article, we report the results of an interim analysis of 81 early-stage lung cancer patients undergoing stereotactic ablative radiotherapy with the CyberKnife M6 robotic radiosurgery system, with the endpoints being treatment efficacy and tolerance. Within a median follow-up of 20 months, a grade 2/3 lung toxicity of no clinical significance was reported in 6% of the patients. A higher biological effective dose and larger irradiation lung volumes were associated with increased toxicity. The projected 24-month local progression-free survival rate was 95%. These results confirm the safety and efficacy and further cement the role of robotic stereotactic ablative radiotherapy for early-stage lung cancer patients as an eventual alternative to surgery. Background/Objectives: Surgery is the primary treatment for early-stage lung cancer. Patients with medically inoperable lung carcinomas and patients who refuse to undergo surgery are treated with definite radiotherapy. Stereotactic ablative radiotherapy (SABR) is a compelling non-invasive therapeutic modality for this group of patients that confers promising results. Methods: We report an interim analysis of an ongoing trial. Eighty-one patients with medically inoperable early-stage (T1,2N0) lung cancer underwent SABR in our institution. SABR was delivered via the CyberKnife M6 robotic radiosurgery system. The endpoints of the analysis were treatment efficacy and tolerance. Results: There were no acute or late toxicities from the skin or the connective tissue of the thorax. A grade 2/3 lung injury of non-clinical significance was noted in 6% of patients, which was directly related to a higher biologically effective dose (BEDα/β = 3) and larger irradiation lung volumes in both univariate and multivariate analyses. A local control (LC) was achieved in 100% of the patients at the first follow-up, and the projected 24-month local progression-free survival (LPFS) rate was 95%. The projected 24-month disease-specific overall survival (OS) was 94%. Conclusions: High LC and OS rates can be achieved with SABR for early-stage lung cancer, with minimal toxicity. This study continues to recruit patients. [ABSTRACT FROM AUTHOR]

Simple Summary: Stereotactic ablative radiation (SAbR) is a focused, high-dose radiation technique used to treat cancers that have spread to the adrenal glands. One of the feared consequences of this therapy is causing adrenal insufficiency in patients, which is a lack of adrenal function; however, the rates and severity at which this occurs in patients are still poorly studied. We studied patients with 66 treated adrenal glands using SAbR, which demonstrated that this technique was effective at controlling cancer sites with a control rate of 75% at 1 year. The risk of patients developing adrenal insufficiency in the entire cohort was significant at 14%, with a median time of 4.3 months. There was a higher risk in patients who had both adrenal glands treated with SAbR, or who had received a prior surgical removal of their other adrenal gland prior to SAbR therapy, with 44% of these patients developing adrenal insufficiency. Background: Adrenal metastases are often treated with stereotactic ablative radiation (SAbR). We aimed to assess the incidence, timing, and factors associated with the development of primary adrenal insufficiency (PAI) following SAbR. Methods: A retrospective cohort study comprised 66 consecutive patients (73% men, median age 61 years) who underwent SAbR for adrenal metastasis. Results: The series encompassed metastases from renal cell carcinoma (41%), lung tumors (38%), colorectal adenocarcinoma (9%), melanoma (5%), and others (7%). Median follow-up was 17 months from SAbR. Nine (14%) patients developed PAI at a median of 4.3 months (range, 0.7–20.2). The incidence of PAI was 44% in patients with prior adrenalectomy receiving unilateral SAbR, 44% with bilateral SAbR, 2% with unaffected contralateral gland, and 0% with bilateral metastases treated with unilateral SAbR. PAI was associated with prior adrenalectomy (odds ratio [OR] 32) and bilateral SAbR (OR 8.2), but not age, sex, metastasis size, or biological effective dose. Post-SAbR 6-month and 1-year local control rates were 82% and 75%, respectively. Conclusions: Patients undergoing SAbR for adrenal metastasis are at high risk of developing PAI. PAI is associated with bilateral SAbR and contralateral adrenalectomy. PAI is unlikely with a remaining unaffected adrenal gland or in the setting of bilateral adrenal metastases with unilateral SAbR. [ABSTRACT FROM AUTHOR]

Background: Multimodal therapy for brain arteriovenous malformations (bAVM) with embolization followed by stereotactic radiosurgery (E + SRS) has shown varying outcomes. Its benefits over other treatment modalities have been questioned. The goal of this systematic review was to determine the factors associated with cure and complication rates of this treatment strategy. Methods: A literature search in Medline and Global Index Medicus, from inception to October 2023, was performed. Studies reporting relevant outcome data from bAVM patients treated with E + SRS were included. Data on several patient, lesion and procedure-related factors were collected. Embolization intent was classified as Targeted (of high-risk features), Devascularizing (feeder embolization/flow reduction) and Occluding (intent-to-cure, nidus embolization). The primary outcome was obliteration rate. Secondary outcomes were post-SRS bleeding (PSB), post-embolization neurological complications (PENC) and post-SRS neurological complications (PSNC). Subgroup analyses included embolic agent, embolization intent and radiosurgery type. Proportional meta-analyses and meta-regressions were performed. Results: Forty-one studies were included in the review. The pooled obliteration rate was 56.45% (95% CI 50.94 to 61.88). Meta-regression analyses showed higher obliteration rates with Copolymers and lower obliteration rates with Devascularizing embolization. The pooled PSB, PENC and PSNC rates were 5.50%, 13.75% and 5.02%, respectively. Meta-regression analyses showed higher rates of PSB, PENC and PSNC with Devascularizing embolization, Liquid & Solid embolic agents and Targeted & Devascularizing intent, respectively. Conclusion: Embolic agent and embolization intent were procedural factors associated with treatment outcomes of E + SRS in the management of bAVM patients. The efficacy and safety profiles favor copolymers as embolic agents and disfavor Devascularizing as embolization intent. Study Registration: The protocol of the systematic review was registered in PROSPERO as CRD42023474171. [ABSTRACT FROM AUTHOR]

AbstractPurposeMethodResultsConclusions\nIMPLICATIONS FOR REHABILITATIONPatient reported outcomes (PROs) in the context of Gamma Knife Stereotactic Radiosurgery (GKSRS) for benign brain tumor have been under-researched. This study examined changes in PROs and adjustment trajectories post-GKSRS.50 adults (54% female) aged on average 53.18 (SD = 14.76) years with benign brain tumor were assessed 1 week before GKSRS, 1–2 weeks post-GKSRS, and at 3-month follow-up. Telephone-based questionnaires of anxiety and depressive symptoms, cognitive function, symptom burden, and health-related quality of life (HRQoL) were completed.Significant improvements in HRQoL, perceived cognitive ability, anxiety, and total brain tumor symptoms were evident between pre-GKSRS and 3-month follow-up. Conversely, there was a significant short-term increase in depressive symptoms at post-GKSRS; however, levels did not differ from pre-GKSRS at follow-up. No significant changes were evident on PROs of headaches or fatigue. About half of the participants (46–51%) experienced reliable improvement in global HRQoL, and one-third (31–34%) reported improved anxiety symptoms. Increased depressive symptoms was seen in 34% of participants post-GKSRS and 18% at follow-up.At 3 months post-GKSRS, improvements in HRQoL, anxiety, perceived cognitive ability, and total brain tumor symptoms were evident. Routine monitoring and support for pre-GKSRS anxiety and depressive symptoms post-GKSRS is recommended.Individuals receiving Gamma Knife radiosurgery for benign brain tumor experience positive impacts on global, emotional, and physical HRQoL, perceived cognitive ability, anxiety, and overall brain tumor symptoms following treatment.Due to heightened levels of anxiety observed prior to treatment, routine screening and support for anxiety are recommended before individuals receive Gamma Knife radiosurgery.Symptoms of depression may increase following Gamma Knife radiosurgery, therefore routine monitoring and management of mood symptoms is recommended after treatment.Evidence-based psychological interventions are needed for healthcare professionals to support individuals undergoing Gamma Knife radiosurgery.Individuals receiving Gamma Knife radiosurgery for benign brain tumor experience positive impacts on global, emotional, and physical HRQoL, perceived cognitive ability, anxiety, and overall brain tumor symptoms following treatment.Due to heightened levels of anxiety observed prior to treatment, routine screening and support for anxiety are recommended before individuals receive Gamma Knife radiosurgery.Symptoms of depression may increase following Gamma Knife radiosurgery, therefore routine monitoring and management of mood symptoms is recommended after treatment.Evidence-based psychological interventions are needed for healthcare professionals to support individuals undergoing Gamma Knife radiosurgery. [ABSTRACT FROM AUTHOR]

Vein of Galen malformations (VOGMs), also known as Vein of Galen Aneurysmal Malformations (VGAMs), are rare and complex cerebrovascular anomalies that pose significant diagnostic and therapeutic challenges. These malformations result from abnormal arteriovenous shunts during embryonic development, leading to a range of severe clinical manifestations, including high-output cardiac failure and hydrocephalus. Advances in prenatal imaging, particularly fetal MRI, have improved early detection, allowing for timely intervention. Endovascular techniques, especially transarterial embolization, have become the primary treatment modality, often preferred over surgical approaches due to their effectiveness and lower risk. However, challenges remain, particularly in managing these malformations in neonates and infants, where the risk of complications is high. Gamma Knife radiosurgery offers a non-invasive alternative for select cases, though its effects are gradual and may carry delayed risks. Despite advancements, the management of VOGMs continues to require a multidisciplinary approach, with ongoing research focused on improving outcomes through a better understanding of the genetic and molecular underpinnings of the disease. Future directions include the integration of genetic studies into clinical practice and the refinement of treatment strategies to optimize outcomes for this complex condition. [ABSTRACT FROM AUTHOR]

Renal cell carcinoma (RCC) is the most common solid tumour of the kidney and accounts for 3% of all cancers. While immune checkpoint inhibitor (ICI)-based combination therapies have emerged as the first-line treatment for metastatic renal cell carcinoma (mRCC), the role of surgery has become more controversial. This review summarizes the evidence, current role and future directions for surgery in mRCC management. The survival benefits of cytoreductive nephrectomy (CN) shown in the interferon era have encountered increasing disputes in the tyrosine-kinase inhibitor (TKI) and ICI eras. Undoubtedly, several systematic reviews based on retrospective data have supported the survival benefits of CN. Nevertheless, 2 prospective trials, CARMENA and SURTIME, proved that sunitinib as the upfront therapy resulted in noninferior survival outcomes compared with immediate CN. The safety of CN does have solid ground in the current literature. Several studies suggested that preoperative systemic therapy did not seem to aggravate perioperative complications or mortality rates, in experienced centres. Meticulous patient selection is the rule of thumb in the modern management of mRCC patients. The limitations of the existing prognostication models, however, must be acknowledged. Clinicians should adopt a multidisciplinary and holistic approach and contemplate all patient, disease, surgeon and socio-economical factors, before deciding who should go for surgery. The advent of metastasis-directed therapy (MDT) and survival benefits of adjuvant pembrolizumab shown in the oligometastatic subgroup, where complete metastasectomy could be achieved (M1 NED), calls for more comparative studies against upfront ICI combinations. In summary, CN brings survival benefits to well-selected good-to-intermediate-risk mRCC patients. Individualized and multidisciplinary care is pivotal. [ABSTRACT FROM AUTHOR]

This research letter discusses a case series of pediatric brain tumors with a specific genetic fusion called MN1::BEND2. The study found that these tumors did not exhibit the typical features of astroblastoma, a type of brain tumor. However, the tumors did show DNA methylation profiles consistent with astroblastoma. The study emphasizes the need for further investigation and optimal treatment for these types of tumors. It also highlights the importance of accurate diagnosis and the need for more research on the clinical responses and long-term outcomes of pediatric patients with MN1-altered tumors. [Extracted from the article]

Purpose: Recent innovations in radiological imaging have enabled the detection of micro-remnant niduses of arteriovenous malformations (AVMs) after gamma knife radiosurgery (GKS), which have not been previously perceptible. Herein, we focus on the difficulty of evaluating micro-remnant AVMs after GKS that are hardly perceptible on conventional examinations and propose integrating follow-up three-dimensional rotational angiography (3D-RA) in the previous gamma plan as a solution. Methods: We retrospectively searched NTT Medical Center Tokyo hospital database for patients with AVMs who underwent both two-dimensional digital subtraction angiography (2D-DSA) and 3D-RA as follow-up for GKS from February 2021 to January 2024. Patients with suspected nidus occlusion on the latest non-contrast-enhanced magnetic resonance angiography (NC-MRA) were included, and contrast-enhanced magnetic resonance angiography (CE-MRA), 2D-DSA, and 3D-RA were evaluated. Results: Twelve patients with 13 AVM sites were defined as having complete nidus occlusion on upfront NC-MRA. On 2D-DSA, seven AVM sites showed the presence of slight remaining AVMs based on the detection of remnant drainage veins, however the nidus was not detected in three cases. Nevertheless, 3D-RA detected micro-remnant niduses in all seven AVM sites, and four patients underwent re-GKS. Nine patients with ten AVM sites also underwent CE-MRA, and six AVM sites were diagnosed with radiation-induced parenchymal injury. Conclusion: Importing the 3D-RA image into the treatment planning has the potential to be more helpful than NC-MRA or CE-MRA to detect micro-remnant AVMs and evaluate the true remnant volume, and may contribute to a more detailed treatment planning, thereby improving the results of GKS retreatment. [ABSTRACT FROM AUTHOR]

Objective: The primary treatment for stage I non-small cell lung cancer (NSCLC) in medically inoperable patients is stereotactic body radiation therapy (SBRT). The current study aimed to retrospectively analyze patients who underwent SBRT. Methods: A total of 188 patients with stage I NSCLC treated with SBRT between 2014 and 2020 were enrolled. Local control (LC), progressionfree survival (PFS), overall survival (OS), and treatment-related toxicities were analyzed. Results: Patients were mostly male (65.7%, n=71), with a median age of 68 (56-88). Based on tumor size and location, 69 patients (63.9%) received between 50 and 60 Gy in 5 fractions, 26 patients (24.1%) received 54 Gy in 3 fractions, 11 patients (10.2%) received 60 Gy in 8 fractions, and 2 patients (1.8%) received 60 Gy in 3 fractions. The median follow-up time was 32 months (12-47 months). Locoregional relapse occurred in 11 patients, among whom 4 (3.7%) developed distant metastasis. The 3-year LC, OS, and PFS rates were 89.5%, 83%, and 72%, respectively. Advanced age and presence of chronic obstructive pulmonary disease were associated with a decreased 3-year OS. In smokers and those with large tumor volumes, PFS decreased to 3 years. No grade 3 or 4 treatment-related toxicities were observed. Conclusion: SBRT is a fast, safe, and valuable therapeutic approach for patients with early-stage medically inoperable NSCLC, providing significant tumor control rates with low toxicity. [ABSTRACT FROM AUTHOR]

Simple Summary: Metastatic renal cell carcinoma (RCC) represents a significant challenge in oncology, and systemic therapy remains the primary treatment modality. Radiation therapy (RT) offers a non-invasive ablative approach to the management of oligometastatic disease, and the use of Stereotactic Ablative Radiotherapy (SABR) has demonstrated remarkably high disease control. Within the broad spectrum of oligometastatic disease, we evaluated the efficacy of SABR on oligorecurrent RCC systemic treatment-naïve, and we aimed to identify predictive factors for long-term disease control. We demonstrated the potential of SABR to delay the need for systemic therapy and confirmed the long-term efficacy of SABR for oligometastatic RCC patients, with a superior benefit for patients with single lung metastasis, potentially refining patient selection processes to tailor treatments. Background: Stereotactic ablative radiotherapy (SABR) is emerging as a potential local treatment option for oligometastatic RCC. This study aims to evaluate the efficacy of SABR in patients with oligorecurrent RCC. Methods: A total of 50 patients with histologically confirmed RCC underwent SABR for oligorecurrence between 2006 and 2022. Eligible patients had up to five extracranial metastases and were systemic treatment-naïve at the time of irradiation. The primary endpoints of the analysis were overall survival (OS), local control (LC), distant metastasis–free survival (DMFS), and time to systemic therapy initiation. Results: The median OS was not reached, with 1- and 3-year OS rates of 93.8% and 77.5%, respectively. LC rates at one and three years were 95.8% and 86.5%, respectively. The median time to systemic therapy initiation was 63.8 months, and the median DMFS was 17.9 months, with one- and three-year rates of 63.4% and 36.6%, respectively. Multiple metastases were a negative predictive factor for DMFS (HR 2.39, p = 0.023), whereas lung metastases were associated with a more favorable outcome (HR 0.38, p = 0.011). Conclusions: SABR offers a valuable treatment option for oligometastatic RCC, demonstrating significant potential for achieving long-term disease control and delaying the need for systemic therapy. [ABSTRACT FROM AUTHOR]

Objective : We investigated how treating large brain metastasis (LBM) using 2-day fraction Gamma Knife radiosurgery (GKRS) affects tumor control and patient survival. A prescription dose of 10.3 Gy was applied for 2 consecutive days, with a biologically effective dose equivalent to a tumor single-fraction dose of 16.05 Gy and a brain single-fraction dose of 15.12 Gy. Methods : Between November 2017 and December 2021, 42 patients (mean age, 68.3 years; range, 50–84 years; male, 29 [69.1%]; female, 13 [30.9%]) with 44 tumors underwent 2-day fraction GKRS to treat large volume brain metastasis. The main cancer types were non-small cell lung cancer (n=16), small cell lung cancer (n=7), colorectal cancer (n=7), breast cancer (n=3), gastric cancer (n=2), and other cancers (n=7). Twenty-one patients (50.0%) had a single LBM, 19 (46.3%) had a single LBM and other metastases, and two had two (4.7%) large brain metastases. At the time of the 2-day fraction GKRS, the tumors had a mean volume of 23.1 mL (range, 12.5–67.4). On each day, radiation was administered at a dose of 10.3 Gy, mainly using a 50% isodose-line. Results : We obtained clinical and magnetic resonance imaging follow-up data for 34 patients (81%) with 35 tumors, who had undergone 2-day fraction GKRS. These patients did not experience acute or late radiation-induced complications during follow-up. The median and mean progression-free survival (PFS) periods were 188 and 194 days, respectively. The local control rates at 6, 9, and 12 months were 77%, 40%, and 34%, respectively. The prognostic factors related to PFS were prior radiotherapy (p=0.019) and lung cancer origin (p=0.041). Other factors such as tumor volumes, each isodose volumes, and peri-GKRS systemic treatment were not significantly related to PFS. The overall survival period of the 44 patients following repeat stereotactic radiosurgery (SRS) ranged from 15–878 days (median, 263±38 days; mean, 174±43 days) after the 2-day fraction GKRS. Eight patients (18.2%) were still alive. Conclusion : Considering the unsatisfactory tumor control, a higher prescription dose should be needed in this procedure as a salvage management. Moreover, in the treatment for LBM with fractionated SRS, using different isodoses and prescription doses at the treatment planning for LBMs should be important. However, this report might be a basic reference with the same fraction number and prescription dose in the treatment for LBMs with frame-based SRS. [ABSTRACT FROM AUTHOR]

Radiation induced changes (RIC) are the most common complications observed post Gamma Knife radiosurgery (GKRS) and may be observed within 6–18 months post procedure. It has been observed that almost one-third of RICs are symptomatic and half of them are persistent. There is no way to predict which patients will develop these changes and to what extent. This was a prospective analytical pilot study with the aim of understanding the role of serum vascular endothelial growth factor (VEGF) and endostatin as predictive factors for clinically symptomatic RIC in intracranial arteriovenous malformations (AVMs) of Spetzler Martin (SM) grade 3 being managed with primary GKRS. A total of 15 patients were analyzed; 60% of them had a history of bleed. The median volume of AVM nidus was 4.36 mL. One-third of the patients had no imaging changes suggestive of RIC at 1 year follow-up and 2 of the patients had symptomatic RIC needing intervention. Before GKRS, the median values of serum concentration of endostatin and VEGF were 34.98 ng/mL and 168.37 pg/mL, respectively. The serum values of VEGF at 1 month post GKRS was much lower than the pre-GKRS values but not found to be predictive of RIC. No correlation could be observed with the levels of serum endostatin and RIC. Some patients may develop resistant edema and necrosis post GKRS for intracranial AVMs, which may warrant medical and surgical intervention. Serum biomarkers like VEGF and endostatin may vary in the post GKRS period and can be used to identify at-risk cases, however more studies are needed to decide on appropriate time of sampling and identify clinically relevant predictive factors. [ABSTRACT FROM AUTHOR]

Prognosis of locally advanced pancreatic cancer (LAPC) remains poor with limited therapeutic options. Radiation therapy in pancreatic cancer has been restricted by the disease's proximity to radiosensitive organs at risk (OAR). However, stereotactic magnetic resonance-guided adaptive radiation therapy (SMART) has demonstrated promise in delivering ablative doses safely. We sought to report clinical outcomes from a UK-based Compassionate Access Programme that provided access to SMART to patients with LAPC. This was a registry retrospective study conducted at a single centre with access to SMART. Patients with LAPC were treated with prescription dose of 40 Gy in 5 fractions. The planning objective was that 98% of PTV received ≥95% of the prescribed dose, prioritising duodenal, stomach and bowel UK SABR consortium constraints. Daily online adaptation was performed using magnetic resonance guidance and on-table re-optimisation. 0–3 months and > 3-month post-treatment-related toxicities, local progression-free survival, metastatic-free survival and overall survival were evaluated. 55 patients were treated with SMART at our institution from 2020 to 2022. Median follow-up from date of diagnosis was 17 months (range 5–37 months). Median age was 69.87% of patients underwent induction chemotherapy. 71% of patients reported 0–1 grade acute toxicity only. No grade >3 acute toxicity was reported. 5 patients (9%) reported a grade 3 toxicity (fatigue, nausea, abdominal pain, duodenal stricture). No grade >3 toxicity after 3 months was reported. 6 (10%) of patients had grade 3 toxicity (fatigue, nausea, abdominal pain, duodenal haemorrhage). Median local PFS post diagnosis was 17 months (95% CI 15.3–18.7). Median OS post diagnosis was 19 months (95% CI 15.9–22.1). One-year local control post SMART was 65%. This is the first UK-reported experience of MR-guided daily adaptive pancreatic SABR. SMART shows promise in delivering ablative doses with acceptable toxicity rates and good clinical outcomes. • No acute or late grade >3 toxicity reported. • Majority of patients (71%) experienced no or grade 1 only acute toxicity. • Acute and late G3 toxicity incidence was 9% and 10% respectively. • 65% of all patients maintained local control at 1 year post SMART. • Median OS was 21 months with chemotherapy followed by consolidatory pancreas SMART. [ABSTRACT FROM AUTHOR]

Purpose: This study examines how MRI distortions affect frame‐based SRS treatments and assesses the need for clinical distortion corrections. Methods: The study included 18 patients with 80 total brain targets treated using frame‐based radiosurgery. Distortion within patients' MRIs were corrected using Cranial Distortion Correction (CDC) software, which utilizes the patient's CT to alter planning MRIs to reduce inherent intra‐cranial distortion. Distortion was evaluated by comparing the original planning target volumes (PTVORIG) to targets contoured on corrected MRIs (PTVCORR). To provide an internal control, targets were also re‐contoured on uncorrected (PTVRECON) MRIs. Additional analysis was done to assess if 1 mm expansions to PTVORIG targets would compensate for patient‐specific distortions. Changes in target volumes, DICE and JACCARD similarity coefficients, minimum PTV dose (Dmin), dose to 95% of the PTV (D95%), and normal tissue receiving 12 Gy (V12Gy), 10 Gy (V10Gy), and 5 Gy (V5Gy) were calculated and evaluated. Student's t‐tests were used to determine if changes in PTVCORR were significantly different than intra‐contouring variability quantified by PTVRECON. Results: PTVRECON and PTVCORR relative changes in volume were 6.19% ± 10.95% and 1.48% ± 32.92%. PTVRECON and PTVCORR similarity coefficients were 0.90 ± 0.08 and 0.73 ± 0.16 for DICE and 0.82 ± 0.12 and 0.60 ± 0.18 for JACCARD. PTVRECON and PTVCORR changes in Dmin were –0.88% ± 8.77% and −12.9 ± 17.3%. PTVRECON and PTVCORR changes in D95% were −0.34% ± 5.89 and −8.68% ± 13.21%. The 1 mm expanded PTVORIG targets did not entirely cover 14 of the 80 PTVCORR targets. Normal tissue changes (V12Gy, V10Gy, V5Gy) calculated with PTVRECON were (−0.09% ± 7.39%, −0.38% ± 5.67%, −0.08% ± 2.04%) and PTVCORR were (−2.14% ± 7.34%, −1.42% ± 5.45%, −0.61% ± 1.93%). Except for V10Gy, all PTVCORR changes were significantly different (p < 0.05) than PTVRECON. Conclusion: MRIs used for SRS target delineation exhibit notable geometric distortions that may compromise optimal dosimetric accuracy. A uniform 1 mm expansion may result in geometric misses; however, the CDC algorithm provides a feasible solution for rectifying distortions, thereby enhancing treatment precision. [ABSTRACT FROM AUTHOR]

Brainstem metastases are challenging to manage owing to the critical neurological structures involved. Although stereotactic radiotherapy (SRT) offers targeted high doses while minimizing damage to adjacent normal tissues, the optimal dose fractionation remains undefined. This study evaluated the efficacy and safety of multifraction SRT with an inhomogeneous dose distribution. This retrospective study included 31 patients who underwent 33 treatments for 35 brainstem lesions using linear accelerator-based multifraction SRT (30 Gy in five fractions, 35 Gy in five fractions or 42 Gy in 10 fractions) with an inhomogeneous dose distribution (median isodose, 51.9%). The outcomes of interest were local failure, toxicity and symptomatic failure. The median follow-up time after brainstem SRT for a lesion was 18.6 months (interquartile range, 10.0–24.3 months; range, 1.8–39.0 months). Grade 2 toxicities were observed in two lesions, and local failure occurred in three lesions. No grade 3 or higher toxicities were observed. The 1-year local and symptomatic failure rates were 8.8 and 16.7%, respectively. Toxicity was observed in two of seven treatments with a gross tumor volume (GTV) greater than 1 cc, whereas no toxicity was observed in treatments with a GTV less than 1 cc. No clear association was observed between the biologically effective dose of the maximum brainstem dose and the occurrence of toxicity. Our findings indicate that multifraction SRT with an inhomogeneous dose distribution offers a favorable balance between local control and toxicity in brainstem metastases. Larger multicenter studies are needed to validate these results and determine the optimal dose fractionation. [ABSTRACT FROM AUTHOR]

Prostate cancer remains a significant global health concern, necessitating continuous research and innovation in treatment modalities. This review explores the currently employed techniques in radiation dose planning and tumor irradiation in the context of prostate cancer management. In addition, we delve into the nuances of expected posttreatment magnetic resonance imaging (MRI) appearances within the gland or in the prostate bed, postradiation tumor recurrence, and its mimics. Radiation therapy (RT) has evolved as a cornerstone in prostate cancer treatment, offering both curative and palliative solutions. Recent developments have seen the emergence of advanced techniques such as intensity-modulated radiation therapy (IMRT) and stereotactic body radiation therapy (SBRT), allowing for precise targeting of cancer cells while minimizing damage to surrounding healthy tissue. The avoidance of normal tissue dose through more conformal dose distribution as in IMRT or proton therapy, improved imaging modalities as in multiparametric magnetic resonance imaging (mpMRI) and prostate positron emission tomography (PET), interventional separation of critical structures from the prostate target, and many other techniques can greatly reduce the side effects of RT. These advancements enhance treatment efficacy and reduce the risk of side effects, promoting improved patient outcomes. [ABSTRACT FROM AUTHOR]

Brainstem metastases (BSM) present a significant neuro‐oncological challenge, resulting in profound neurological deficits and poor survival outcomes. Stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (FSRT) offer promising therapeutic avenues for BSM despite their precarious location. This international multicenter study investigates the efficacy and safety of SRS and FSRT in 136 patients with 144 BSM treated at nine institutions from 2005 to 2022. The median radiographic and clinical follow‐up periods were 6.8 and 9.4 months, respectively. Predominantly, patients with BSM were managed with SRS (69.4%). The median prescription dose and isodose line for SRS were 18 Gy and 65%, respectively, while for FSRT, the median prescription dose was 21 Gy with a median isodose line of 70%. The 12‐, 24‐, and 36‐month local control (LC) rates were 82.9%, 71.4%, and 61.2%, respectively. Corresponding overall survival rates at these time points were 61.1%, 34.7%, and 19.3%. In the multivariable Cox regression analysis for LC, only the minimum biologically effective dose was significantly associated with LC, favoring higher doses for improved control (in Gy, hazard ratio [HR]: 0.86, p <.01). Regarding overall survival, good performance status (Karnofsky performance status, ≥90%; HR: 0.43, p <.01) and prior whole brain radiotherapy (HR: 2.52, p <.01) emerged as associated factors. In 14 BSM (9.7%), treatment‐related adverse events were noted, with a total of five (3.4%) radiation necrosis. SRS and FSRT for BSM exhibit efficacy and safety, making them suitable treatment options for affected patients. [ABSTRACT FROM AUTHOR]

Stereotactic radiosurgery (SRS) is an effective treatment strategy for cerebral arteriovenous malformations (AVMs). Aggressive treatment achieving complete obliteration is necessary to prevent further intracranial hemorrhage and neurological deficits. However, SRS treatment of large AVMs (>10 cm3) is challenging. To prevent toxicity in the normal brain tissue, it is imperative to reduce the radiation dose as the lesion volume increases; however, this also reduces the rate of obliteration. In this study, we review the various radiosurgical approaches for treating large AVMs and their outcomes, and suggest ways to improve treatment outcomes during SRS for large AVMs. [ABSTRACT FROM AUTHOR]

Spine stereotactic body radiation therapy (SBRT) for the treatment of metastatic disease is increasingly utilized owing to improved pain and local control over conventional regimens. Vertebral body collapse (VBC) is an important toxicity following spine SBRT. We investigated our institutional experience with spine SBRT as it relates to VBC and spinal instability neoplastic score (SINS). Records of 83 patients with 100 spinal lesions treated with SBRT between 2007 and 2022 were reviewed. Clinical information was abstracted from the medical record. The primary endpoint was post-treatment VBC. Logistic univariate analysis was performed to identify clinical factors associated with VBC. Median dose and number of fractions used was 24 Gy and 3 fractions, respectively. There were 10 spine segments that developed VBC (10%) after spine SBRT. Median time to VBC was 2.4 months. Of the 11 spine segments that underwent kyphoplasty prior to SBRT, none developed subsequent VBC. No factors were associated with VBC on univariate analysis. The rate of vertebral body collapse following spine SBRT is low. Prophylactic kyphoplasty may provide protection against VBC and should be considered for patients at high risk for fracture. [ABSTRACT FROM AUTHOR]

Seventy years ago, Robin Mole introduced the concept of the abscopal effect to describe a rare phenomenon. This occurs when local radiation triggers an immune-mediated reduction in tumors outside the treated area but within the same organism. Observing this effect has been linked to improved overall and progression-free survival in patients who experience it. While the abscopal effect was once considered rare, it is now being observed more frequently due to the combination of radiation with immunotherapy. As a result, more researchers are exploring this study area, which shows promise for excellent results. This review focuses explicitly on the immunological implications of activating the abscopal effect through ionizing radiation in the central nervous system and explores the potentially involved immunological pathways.

Purpose: The purpose of this study was to systematically examine the normal tissue objective (NTO) function by comparing its variations for planning solitary brain metastasis with intensity-modulated and volumetric-modulated arc radiosurgery techniques. Materials and Methods: Twenty-two cases were retrospectively planned with two NTO parameter sets named A and B using intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT) techniques. The Type A set used slope, k = 0.4 mm−1 plus end dose, De = 20%, whereas the Type B set used k = 1.0 mm−1 plus De = 10%. The resulting four plan types were assessed using mean dose to 5 mm exterior ring, normal brain receiving 12 Gy (V12), 5 Gy total brain dose volume (V5), gradient index (R50%), focal index (FI), Paddick conformity index (PCI), prescription isodose surface (PIDS), and MU/Gy. Results: Brain doses were significantly lower for VMAT than for IMRT. R50% was more favorable for VMAT than for IMRT for each planning target volume (PTV). The mean FI was comparable between the corresponding IMRT and VMAT plan types. PCI was better for the IMRT_A plan type. PIDS was significantly lower for Type B plans than Type A for both techniques. For PTVs

Backgrounds/Aims This study explored the initial institutional experience of using gold fiducial markers for stereotactic body radiotherapy (SBRT) in treating malignant hepatic tumors using real-time ultrasound-computed tomography (CT)/magnetic resonance (MR) imaging fusion-guided percutaneous placement. Methods From May 2021 to August 2023, 19 patients with 25 liver tumors that were invisible on pre-contrast CT received fiducial markers following these guidelines. Postprocedural scans were used to confirm their placement. We assessed technical and clinical success rates and monitored complications. The implantation of fiducial markers facilitating adequate treatment prior to SBRT, which was achieved in 96% of the cases (24 of 25 tumors), was considered technical success. Clinical success was the successful completion of SBRT without evidence of marker displacement and was achieved in 88% of cases (22 of 25 tumors). Complications included one major subcapsular hematoma and marker migration into the right atrium in two cases, which prevented SBRT. Results Among the treated tumors, 20 of 24 (83.3%) showed a complete response, three of 24 (12.5%) remained stable, and one of 24 (4.2%) progressed during an average 11.7-month follow-up (range, 2-32 months). Conclusions This study confirms that percutaneous gold fiducial marker placement using real-time CT/MR guidance is effective and safe for SBRT in hepatic tumors, but warns of marker migration risks, especially near the hepatic veins and in subcapsular locations. Using fewer markers than traditionally recommended-typically two per patient, the outcomes were still satisfactory, particularly given the increased risk of migration when markers were placed near major hepatic veins.