Preop SRS continues to emerge as an option for resectable brain metastases. Several trials and large series have explored different dose-fractionation regimens and even dose escalation. Here is a phase 1 study from UAB that enrolled 20 patients planned to undergo resection of a brain metastasis. They prescribed 15 Gy in 1 fraction for tumors ranging from 2 to 6 cm in size. When combined with another 75 patients treated with the same regimen off-trial, the rate of nodular leptomeningeal disease was significantly lower than a cohort of patients who received postop SRS (7% v 27%). Local failure was similar between arms (15% v 18%). Pre-operative radiosurgery of at least 15 Gy is safe for tumors up to 6 cm, and the pre-op paradigm remains a promising strategy to mitigate surgical seeding. | Hoyle, Pract Radiat Oncol 2025
