2023
Local Control and Survival Outcomes After Stereotactic Radiosurgery for Brain Metastases From Gastrointestinal Primaries: An International Multicenter Analysis
Singh R, Bowden G, Mathieu D, Perlow H, Palmer J, Elhamdani S, Shepard M, Liang Y, Nabeel A, Reda W, Tawadros S, Abdelkarim K, El-Shehaby A, Emad R, Elazzazi A, Warnick R, Gozal Y, Daly M, McShane B, Addis-Jackson M, Karthikeyan G, Smith S, Picozzi P, Franzini A, Kaisman-Elbaz T, Yang H, Wei Z, Legarreta A, Hess J, Templeton K, Pikis S, Mantziaris G, Simonova G, Liscak R, Peker S, Samanci Y, Chiang V, Niranjan A, Kersh C, Lee C, Trifiletti D, Lunsford L, Sheehan J. Local Control and Survival Outcomes After Stereotactic Radiosurgery for Brain Metastases From Gastrointestinal Primaries: An International Multicenter Analysis. Neurosurgery 2023, 93: 592-598. PMID: 36942965, DOI: 10.1227/neu.0000000000002456.Peer-Reviewed Original ResearchConceptsKarnofsky performance statusStereotactic radiosurgeryOverall survivalBrain metastasesUnivariate analysisLocal controlGI primaryExtracranial metastasesPrognostic factorsBrain metastases treated with stereotactic radiosurgeryAssociated with inferior LCAssociated with inferior OSMedian Karnofsky performance statusEvaluate potential prognostic factorsInternational multicenter analysisPlanning target volumePotential prognostic factorsKaplan-Meier analysisOne-yearProportional hazards modelInferior LCInferior OSOS ratesLC ratesGastrointestinal primary
2021
Adverse radiation effects in volume-staged radiosurgery for large arteriovenous malformations: a multiinstitutional study.
Seymour ZA, Chan JW, McDermott MW, Grills I, Ye H, Kano H, Lehocky CA, Jacobs RC, Lunsford LD, Chytka T, Liščák R, Lee CC, Yang HC, Ding D, Sheehan JP, Feliciano CE, Rodriguez-Mercado R, Chiang VL, Hess JA, Sommaruga S, McShane B, Lee JYK, Vasas LT, Kaufmann AM, Sneed PK. Adverse radiation effects in volume-staged radiosurgery for large arteriovenous malformations: a multiinstitutional study. Journal Of Neurosurgery 2021, 136: 503-511. PMID: 34450589, DOI: 10.3171/2020.12.jns201866.Peer-Reviewed Original ResearchConceptsAdverse radiation effectsLarge arteriovenous malformationsArteriovenous malformationsVS-SRSLobe involvementSymptomatic adverse radiation effectsVolume-staged stereotactic radiosurgeryMedian margin doseOptimal treatment paradigmAVM nidus volumeTemporal lobe involvementVolume-staged radiosurgeryParietal lobe involvementMultiinstitutional cohortRadiosurgical centersMargin doseMedian ageRetrospective reviewEntire nidusMaximal linear dimensionMultiinstitutional studyNidus volumeTreatment paradigmStereotactic radiosurgeryPatientsOutcomes of Stereotactic Radiosurgery and Immunotherapy in Renal Cell Carcinoma Patients With Brain Metastases
Uezono H, Nam D, Kluger HM, Sznol M, Hurwitz M, Yu JB, Chiang VL. Outcomes of Stereotactic Radiosurgery and Immunotherapy in Renal Cell Carcinoma Patients With Brain Metastases. American Journal Of Clinical Oncology 2021, 44: 495-501. PMID: 34432667, DOI: 10.1097/coc.0000000000000849.Peer-Reviewed Original ResearchConceptsImmune checkpoint inhibitorsRCC brain metastasesBrain metastasesRenal cell carcinomaStereotactic radiosurgeryOverall survivalUse of ICIsCentral nervous system toxicityRenal cell carcinoma patientsImpact of immunotherapyLocal control outcomesMedian overall survivalCell carcinoma patientsKaplan-Meier curvesNervous system toxicityBetter median OSLog-rank testMann-Whitney U testMargin doseMedian OSNonimmunotherapy groupSRS doseCheckpoint inhibitorsImmunotherapy groupCarcinoma patients
2020
A prospective multicenter study of laser ablation for drug resistant epilepsy – One year outcomes
Landazuri P, Shih J, Leuthardt E, Ben-Haim S, Neimat J, Tovar-Spinoza Z, Chiang V, Spencer D, Sun D, Fecci P, Baumgartner J. A prospective multicenter study of laser ablation for drug resistant epilepsy – One year outcomes. Epilepsy Research 2020, 167: 106473. PMID: 33045664, DOI: 10.1016/j.eplepsyres.2020.106473.Peer-Reviewed Original ResearchConceptsMesial temporal lobe epilepsyLaser interstitial thermal therapySeizure outcomeLife scoresPotential clinical characteristicsMulti-center registryDrug-resistant epilepsyProspective multicenter studyEffective treatment optionTemporal lobe epilepsyFocal cortical dysplasiaSocial functioning scoresInterstitial thermal therapyEngel IPain scoresAdverse eventsClinical characteristicsSeizure worryEpilepsy typeResistant epilepsySurgical treatmentShorter hospitalizationCortical dysplasiaHypothalamic hamartomaLobe epilepsyLaser interstitial thermal therapy (LITT) vs. bevacizumab for radiation necrosis in previously irradiated brain metastases
Sujijantarat N, Hong CS, Owusu KA, Elsamadicy AA, Antonios JP, Koo AB, Baehring JM, Chiang VL. Laser interstitial thermal therapy (LITT) vs. bevacizumab for radiation necrosis in previously irradiated brain metastases. Journal Of Neuro-Oncology 2020, 148: 641-649. PMID: 32602021, DOI: 10.1007/s11060-020-03570-0.Peer-Reviewed Original ResearchConceptsLaser interstitial thermal therapyLonger overall survivalRadiation necrosisInterstitial thermal therapyBrain metastasesOverall survivalMedian volume decreaseMedian volume increaseBrain metastasis patientsPre-treatment patient characteristicsRetrospective chart reviewResultsTwenty-five patientsPre-treatment factorsBevacizumab patientsChart reviewMetastasis patientsLocal recurrencePatient characteristicsTreatment optionsTreatment responseBevacizumabPatientsLesional volumeThermal therapyStatistical significanceLaser Ablation of Abnormal Neurological Tissue Using Robotic NeuroBlate System (LAANTERN): 12-Month Outcomes and Quality of Life After Brain Tumor Ablation
Kim AH, Tatter S, Rao G, Prabhu S, Chen C, Fecci P, Chiang V, Smith K, Williams BJ, Mohammadi AM, Judy K, Sloan A, Tovar-Spinoza Z, Baumgartner J, Hadjipanayis C, Leuthardt EC. Laser Ablation of Abnormal Neurological Tissue Using Robotic NeuroBlate System (LAANTERN): 12-Month Outcomes and Quality of Life After Brain Tumor Ablation. Neurosurgery 2020, 87: e338-e346. PMID: 32315434, PMCID: PMC7534487, DOI: 10.1093/neuros/nyaa071.Peer-Reviewed Original ResearchConceptsKarnofsky performance scorePrimary tumorBaseline Karnofsky performance scoreCancer Therapy-BrainPostprocedure hospital stayReal-world registryPatient-reported QOLNeurological tissuesHigh-grade gliomasQuality of lifeReal-world outcomesBaseline comorbiditiesHospital stayAdverse eventsMost patientsOverall survivalMedian ageBrain tumor ablationRadiation necrosisPatient populationMetastatic cancerFunctional assessmentSurvival rateBaseline levelsQoL
2019
Dose response and architecture in volume staged radiosurgery for large arteriovenous malformations: A multi-institutional study
Seymour ZA, Chan JW, Sneed PK, Kano H, Lehocky CA, Jacobs RC, Ye H, Chytka T, Liscak R, Lee CC, Yang HC, Ding D, Sheehan J, Feliciano CE, Rodriguez-Mercado R, Chiang VL, Hess JA, Sommaruga S, McShane B, Lee J, Vasas LT, Kaufmann AM, Grills I, McDermott MW. Dose response and architecture in volume staged radiosurgery for large arteriovenous malformations: A multi-institutional study. Radiotherapy And Oncology 2019, 144: 180-188. PMID: 31835173, DOI: 10.1016/j.radonc.2019.09.019.Peer-Reviewed Original ResearchConceptsLarge arteriovenous malformationsArteriovenous malformationsVS-SRSMargin doseObliteration rateVolume-staged stereotactic radiosurgeryMedian margin doseHigh-risk lesionsOptimal treatment paradigmAVM nidus volumeMulti-institutional studyImproved ratesCompact nidusEvaluable patientsMedian followRadiosurgical centersOverall survivalUpfront treatmentComplete responseMedian ageRetrospective reviewCure rateRare lesionsPrior embolizationTreatment paradigmPrognosticating brain tumor patient survival after laser thermotherapy: Comparison between neuroradiological reading and semi-quantitative analysis of MRI data
Hanna JM, Temares D, Hyder F, Rothman DL, Fulbright RK, Chiang VL, Coman D. Prognosticating brain tumor patient survival after laser thermotherapy: Comparison between neuroradiological reading and semi-quantitative analysis of MRI data. Magnetic Resonance Imaging 2019, 65: 45-54. PMID: 31675529, DOI: 10.1016/j.mri.2019.09.011.Peer-Reviewed Original ResearchA Proposed Grading Scale for Predicting Outcomes After Stereotactic Radiosurgery for Dural Arteriovenous Fistulas
Mohammed N, Hung YC, Chen CJ, Xu Z, Schlesinger D, Kano H, Chiang V, Hess J, Lee J, Mathieu D, Kaufmann AM, Grills IS, Cifarelli CP, Vargo JA, Chytka T, Janouskova L, Feliciano CE, Mercado RR, Lunsford LD, Sheehan JP. A Proposed Grading Scale for Predicting Outcomes After Stereotactic Radiosurgery for Dural Arteriovenous Fistulas. Neurosurgery 2019, 87: 247-255. PMID: 31584074, PMCID: PMC7528658, DOI: 10.1093/neuros/nyz401.Peer-Reviewed Original ResearchConceptsDural arteriovenous fistulaCranial dural arteriovenous fistulasCortical venous refluxFavorable outcomeStereotactic radiosurgeryGrading systemIntracerebral hemorrhageArteriovenous fistulaScoring systemGrading scaleKaplan-Meier analysisPrior intracerebral hemorrhageClass II patientsLogistic regression analysisPractical grading systemDAVF obliterationVenous refluxII patientsClinical parametersSinus locationPredicting OutcomeSystematic reviewClass IIIPatientsROC analysisSurvival and prognostic factors in patients with gastrointestinal cancers and brain metastases: have we made progress?
Sperduto PW, Fang P, Li J, Breen W, Brown PD, Cagney D, Aizer A, Yu J, Chiang V, Jain S, Gaspar LE, Myrehaug S, Sahgal A, Braunstein S, Sneed P, Cameron B, Attia A, Molitoris J, Wu CC, Wang TJC, Lockney N, Beal K, Parkhurst J, Buatti JM, Shanley R, Lou E, Tandberg DD, Kirkpatrick JP, Shi D, Shih HA, Chuong M, Saito H, Aoyama H, Masucci L, Roberge D, Mehta MP. Survival and prognostic factors in patients with gastrointestinal cancers and brain metastases: have we made progress? Translational Research 2019, 208: 63-72. PMID: 30885538, PMCID: PMC6527460, DOI: 10.1016/j.trsl.2019.02.011.Peer-Reviewed Original ResearchConceptsGI cancer patientsBrain metastasesGraded Prognostic AssessmentCancer patientsPrognostic factorsNew brain metastasesLarge contemporary cohortPrognosis of patientsLog-rank testMedian survival estimatesContemporary cohortPrognostic indexClinical parametersGastrointestinal cancerPrimary diagnosisPrognostic assessmentRetrospective IRBPatientsFirst treatmentDemographic dataSurvival estimatesCurrent cohortCohortTreatmentPrognosisLocal tumor response and survival outcomes after combined stereotactic radiosurgery and immunotherapy in non-small cell lung cancer with brain metastases.
Singh C, Qian JM, Yu JB, Chiang VL. Local tumor response and survival outcomes after combined stereotactic radiosurgery and immunotherapy in non-small cell lung cancer with brain metastases. Journal Of Neurosurgery 2019, 132: 512-517. PMID: 30771783, DOI: 10.3171/2018.10.jns181371.Peer-Reviewed Original ResearchConceptsAnti-PD-1 therapyKarnofsky performance statusBrain metastasesLung cancer patientsStereotactic radiosurgeryCT groupIT groupCancer patientsNon-small cell lung cancer patientsNon-small cell lung cancerCell lung cancer patientsAntibody-positive patientsGraded Prognostic AssessmentCox regression analysisCell lung cancerMedian survival timeLocal tumor responseWhole study groupMann-Whitney U testTerms of survivalLesional responseMedian survivalPerformance statusWorse survivalComplete response
2018
Quality of life outcomes for brain metastasis patients treated with stereotactic radiosurgery: pre-procedural predictive factors from a prospective national registry.
Sheehan JP, Grills I, Chiang VL, Dong H, Berg A, Warnick RE, Kondziolka D, Kavanagh B. Quality of life outcomes for brain metastasis patients treated with stereotactic radiosurgery: pre-procedural predictive factors from a prospective national registry. Journal Of Neurosurgery 2018, 131: 1848-1854. PMID: 30579284, DOI: 10.3171/2018.8.jns181599.Peer-Reviewed Original ResearchConceptsQuality of lifeBrain metastasis patientsBrain metastasesStereotactic radiosurgeryMetastasis patientsEarly stereotactic radiosurgeryPre-procedural factorsProspective national registryPain/discomfortKarnofsky Performance Scale statusAnxiety/depressionMultivariate linear regression modelRadiological responseInitial presentationPatients' qualityMale sexPredictive factorsNational registryTreatment attributesMedical treatmentPatientsMetastasisSubscoresLife outcomesLife factorsUpfront Magnetic Resonance Imaging-Guided Stereotactic Laser-Ablation in Newly Diagnosed Glioblastoma: A Multicenter Review of Survival Outcomes Compared to a Matched Cohort of Biopsy-Only Patients.
Mohammadi AM, Sharma M, Beaumont TL, Juarez KO, Kemeny H, Dechant C, Seas A, Sarmey N, Lee BS, Jia X, Fecci PE, Baehring J, Moliterno J, Chiang VL, Ahluwalia MS, Kim AH, Barnett GH, Leuthardt EC. Upfront Magnetic Resonance Imaging-Guided Stereotactic Laser-Ablation in Newly Diagnosed Glioblastoma: A Multicenter Review of Survival Outcomes Compared to a Matched Cohort of Biopsy-Only Patients. Neurosurgery 2018, 85: 762-772. PMID: 30476325, PMCID: PMC7054708, DOI: 10.1093/neuros/nyy449.Peer-Reviewed Original ResearchConceptsProgression-free survivalDisease-specific deathOverall survivalChemo/radiotherapyPrognostic groupsOnly cohortNGBM patientsSpecific deathTumor volumeBiopsy-only patientsMedian tumor volumeFavorable prognostic factorRadiation/chemotherapyEffective treatment modalityStereotactic laser ablationMagnetic resonance imagingLA cohortMatched CohortMulticenter reviewPrognostic factorsUpfront treatmentIndependent predictorsSurvival outcomesTreatment modalitiesTumor locationLong-Term Survival of Patients With Melanoma With Active Brain Metastases Treated With Pembrolizumab on a Phase II Trial
Kluger HM, Chiang V, Mahajan A, Zito CR, Sznol M, Tran T, Weiss SA, Cohen JV, Yu J, Hegde U, Perrotti E, Anderson G, Ralabate A, Kluger Y, Wei W, Goldberg SB, Jilaveanu LB. Long-Term Survival of Patients With Melanoma With Active Brain Metastases Treated With Pembrolizumab on a Phase II Trial. Journal Of Clinical Oncology 2018, 37: 52-60. PMID: 30407895, PMCID: PMC6354772, DOI: 10.1200/jco.18.00204.Peer-Reviewed Original ResearchConceptsBrain metastasis responseBrain metastasesMetastasis responseAdverse eventsAnti-programmed cell death-1 (PD-1) agentsDeath ligand 1 (PD-L1) expressionModified Response Evaluation CriteriaPhase II clinical trialActive brain metastasesAsymptomatic brain metastasesCD8 cell densityNeurologic adverse eventsPembrolizumab-treated patientsUse of pembrolizumabMelanoma brain metastasesPrimary end pointLigand 1 expressionPhase II trialResponse Evaluation CriteriaT-cell infiltratesUntreated brain metastasesDeath ligand 1Two-year survivalOverall survival timeResult of progressionBreast cancer patients with brain metastasis undergoing GKRS
Abu-Khalaf M, Muralikrishnan S, Hatzis C, Canchi D, Yu JB, Chiang V. Breast cancer patients with brain metastasis undergoing GKRS. Breast Cancer 2018, 26: 147-153. PMID: 30182250, DOI: 10.1007/s12282-018-0903-3.Peer-Reviewed Original ResearchConceptsWhole-brain radiation therapyGamma knife radiosurgeryKarnofsky performance statusBrain metastasesOverall survivalBackgroundBreast cancerSurgical resectionTime of GKRSFirst gamma knife radiosurgeryFirst GKRS treatmentBrain radiation therapyBreast cancer patientsComprehensive cancer centerGKRS treatmentNeurocognitive preservationResultsMedian agePerformance statusMethodsThe recordsNeurological deathSuch patientsMultivariable analysisRetrospective studySurvival outcomesSystemic diseaseCancer CenterEstimating survival for renal cell carcinoma patients with brain metastases: an update of the Renal Graded Prognostic Assessment tool
Sperduto PW, Deegan BJ, Li J, Jethwa KR, Brown PD, Lockney N, Beal K, Rana NG, Attia A, Tseng CL, Sahgal A, Shanley R, Sperduto WA, Lou E, Zahra A, Buatti JM, Yu JB, Chiang V, Molitoris JK, Masucci L, Roberge D, Shi DD, Shih HA, Olson A, Kirkpatrick JP, Braunstein S, Sneed P, Mehta MP. Estimating survival for renal cell carcinoma patients with brain metastases: an update of the Renal Graded Prognostic Assessment tool. Neuro-Oncology 2018, 20: 1652-1660. PMID: 30418657, PMCID: PMC6231200, DOI: 10.1093/neuonc/noy099.Peer-Reviewed Original ResearchConceptsPrognostic assessment toolsBrain metastasesRenal cell carcinomaMedian survivalPrognostic factorsAdditional significant prognostic factorsRenal cell carcinoma patientsRetrospective institutional review boardNew brain metastasesKarnofsky performance statusOverall median survivalCell carcinoma patientsSignificant prognostic factorsFuture clinical trialsClinical decision makingInstitutional review boardAssessment toolPerformance statusCommon complicationExtracranial metastasesHazard ratioCarcinoma patientsContemporary cohortRCC patientsWorse prognosisLaser ablation after stereotactic radiosurgery: a multicenter prospective study in patients with metastatic brain tumors and radiation necrosis.
Ahluwalia M, Barnett GH, Deng D, Tatter SB, Laxton AW, Mohammadi AM, Leuthardt E, Chamoun R, Judy K, Asher A, Essig M, Dietrich J, Chiang VL. Laser ablation after stereotactic radiosurgery: a multicenter prospective study in patients with metastatic brain tumors and radiation necrosis. Journal Of Neurosurgery 2018, 130: 804-811. PMID: 29726782, DOI: 10.3171/2017.11.jns171273.Peer-Reviewed Original ResearchMeSH KeywordsAblation TechniquesAdultAgedBrain NeoplasmsFemaleHumansKarnofsky Performance StatusLaser TherapyMagnetic Resonance ImagingMaleMiddle AgedNecrosisNeoplasm Recurrence, LocalPostoperative ComplicationsProgression-Free SurvivalProspective StudiesQuality of LifeRadiation InjuriesRadiosurgeryTreatment OutcomeConceptsProgression-free survivalQuality of lifeKarnofsky Performance ScaleMulticenter prospective studyKPS scoreRecurrent tumorsStereotactic radiosurgeryOverall survivalProspective studyRadiation necrosisNeuro-Oncology Brain Metastases criteriaLocal progression-free survivalMedian KPS scoreSteroid sparing effectMetastatic brain tumorsLength of stayPercent of subjectsDuration of survivalOverall event rateSignificant differencesMajority of casesMetastasis (TNM) criteriaOS advantageProgression patientsBrain metastasesStereotactic Radiosurgery for Trigeminal Neuralgia in Patients With Multiple Sclerosis: A Multicenter Study.
Xu Z, Mathieu D, Heroux F, Abbassy M, Barnett G, Mohammadi AM, Kano H, Caruso J, Shih HH, Grills IS, Lee K, Krishnan S, Kaufmann AM, Lee JYK, Alonso-Basanta M, Kerr M, Pierce J, Kondziolka D, Hess JA, Gerrard J, Chiang V, Lunsford LD, Sheehan JP. Stereotactic Radiosurgery for Trigeminal Neuralgia in Patients With Multiple Sclerosis: A Multicenter Study. Neurosurgery 2018, 84: 499-505. PMID: 29688562, DOI: 10.1093/neuros/nyy142.Peer-Reviewed Original ResearchConceptsRecurrence-free rateTrigeminal neuralgiaStereotactic radiosurgeryPain responsePain controlMultiple sclerosisMS-related trigeminal neuralgiaFavorable initial responseReasonable pain controlRetrospective cohort studyMedian latency periodLarge patient seriesGamma Knife CenterFacial pain responsesFacial numbnessCohort studyClinical outcomesMedical managementPatient seriesMulticenter studySurgical interventionPatientsLatency periodRisk profileInitial responseEffect of Targeted Therapies on Prognostic Factors, Patterns of Care, and Survival in Patients With Renal Cell Carcinoma and Brain Metastases
Sperduto PW, Deegan BJ, Li J, Jethwa KR, Brown PD, Lockney N, Beal K, Rana NG, Attia A, Tseng CL, Sahgal A, Shanley R, Sperduto WA, Lou E, Zahra A, Buatti JM, Yu JB, Chiang V, Molitoris JK, Masucci L, Roberge D, Shi DD, Shih HA, Olson A, Kirkpatrick JP, Braunstein S, Sneed P, Mehta MP. Effect of Targeted Therapies on Prognostic Factors, Patterns of Care, and Survival in Patients With Renal Cell Carcinoma and Brain Metastases. International Journal Of Radiation Oncology • Biology • Physics 2018, 101: 845-853. PMID: 29976497, PMCID: PMC6925530, DOI: 10.1016/j.ijrobp.2018.04.006.Peer-Reviewed Original ResearchMeSH KeywordsAdolescentAdultAgedAged, 80 and overAngiogenesis InhibitorsAntineoplastic AgentsBrain NeoplasmsCarcinoma, Renal CellCause of DeathCranial IrradiationCytokinesFemaleHemoglobinsHumansImmunotherapyKarnofsky Performance StatusKidney NeoplasmsMaleMiddle AgedMultivariate AnalysisPrognosisRadiosurgeryRetrospective StudiesYoung AdultConceptsPatterns of careNew brain metastasesBrain metastasesLarge contemporary cohortPrognostic factorsMedian survivalContemporary cohortRCC patientsDiagnosis of BMWhole-brain radiation therapyRenal cell carcinoma patientsRetrospective institutional review boardBrain metastasis therapySystemic treatment optionsAdditional prognostic factorsCell carcinoma patientsRenal cell carcinomaInstitutional review boardNonneurologic causesCarcinoma patientsImproved survivalNeurologic causesMultivariable analysisClinical parametersPresent cohortMulti-institutional competing risks analysis of distant brain failure and salvage patterns after upfront radiosurgery without whole brain radiotherapy for brain metastasis
McTyre E, Ayala-Peacock D, Contessa J, Corso C, Chiang V, Chung C, Fiveash J, Ahluwalia M, Kotecha R, Chao S, Attia A, Henson A, Hepel J, Braunstein S, Chan M. Multi-institutional competing risks analysis of distant brain failure and salvage patterns after upfront radiosurgery without whole brain radiotherapy for brain metastasis. Annals Of Oncology 2018, 29: 497-503. PMID: 29161348, DOI: 10.1093/annonc/mdx740.Peer-Reviewed Original ResearchConceptsDistant brain failureWhole brain radiotherapyUpfront stereotactic radiosurgerySalvage whole brain radiotherapySalvage stereotactic radiosurgeryBrain metastasesStereotactic radiosurgerySystemic diseaseMultivariate analysisBrain radiotherapyBrain failureDecreased hazardMelanoma histologyProgressive systemic diseaseWidespread systemic diseaseSystemic disease statusLower KPSSRS doseUpfront radiosurgeryIncreased hazardCompeting Risk AnalysisEarly deathAcademic centersPatientsMetastasis