{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,2]],"date-time":"2026-10-02T03:56:23Z","timestamp":1790913383547,"version":"4.1.0"},"reference-count":28,"publisher":"Oxford University Press (OUP)","issue":"1","license":[{"start":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T00:00:00Z","timestamp":1788220800000},"content-version":"vor","delay-in-days":243,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,1,12]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>We evaluated the outcome of radiosurgically treated patients with \u226510 brain metastases (BM), compared to patients &amp;lt;10 BM.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Patients, who underwent at least one Gamma Knife radiosurgical (GKRS) treatment for at least one BM without previous Central Nervous System (CNS) treatments, were retrospectively divided into 2 groups: (1)\u2009&amp;lt;\u200910 or (2)\u2009\u2265\u200910 BM.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>At GKRS1, 1293 patients had &amp;lt;10 BM and 126 patients had \u226510 BM. The estimated median survival after GKRS1 was significantly longer in patients with &amp;lt;10 BM (9.9 months), compared to patients with \u226510 BM at GKRS1 (5.3 months; P\u2009&amp;lt;\u2009.001). Age &amp;gt;65 years (P\u2009&amp;lt;\u2009.001), male sex (P\u2009=\u2009.001), Karnofsky Performance Status Scale &amp;lt;80 (P\u2009&amp;lt;\u2009.001), presence of extracranial metastases (P\u2009=\u2009.008), presence of neurological symptoms (P\u2009=\u2009.019), a cumulative BM volume of all BM treated at GKRS1\u2009\u2265\u200910 cm3 (P\u2009=\u2009.017), no concomitant immunotherapy or targeted therapy at GKRS1 (P\u2009&amp;lt;\u2009.001), and the number of \u226510 BM at GKRS1 (P\u2009&amp;lt;\u2009.001) were identified as independent prognostic factors for an increased risk of death. In patients with \u226510 BM, poor clinical condition, a cumulative BM volume of all BM treated \u226525 cm3, and no concomitant immunotherapy or targeted therapy at GKRS1 were identified as significant independent prognostic factors. The occurrence of post-radiosurgical complications and local tumor control did not differ between the groups.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>In addition to BM count, multiple factors may influence survival and should be considered during the pre-radiosurgery assessment. GKRS represents a safe and effective first-line treatment method even for patients with \u226510 BM, particularly in the era of modern systemic therapies.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/noajnl\/vdag229","type":"journal-article","created":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T21:20:23Z","timestamp":1788297623000},"source":"Crossref","is-referenced-by-count":0,"title":["How safe and effective is radiosurgical treatment for patients with 10 or more brain metastases?"],"prefix":"10.1093","volume":"8","author":[{"given":"Anna","family":"Cho","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Medical University of Vienna , Vienna,","place":["Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thore","family":"Jankowski","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Medical University of Vienna , Vienna,","place":["Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yiru","family":"Chen","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Medical University of Vienna , Vienna,","place":["Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lukas","family":"Kohlmaier","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Medical University of Vienna , Vienna,","place":["Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brigitte","family":"Gatterbauer","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Medical University of Vienna , Vienna,","place":["Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Philip","family":"Lederer","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Medical University of Vienna , Vienna,","place":["Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lukas","family":"Haider","sequence":"additional","affiliation":[{"name":"Department of Biomedical Imaging and Image-guided Therapy, Division of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna , Vienna,","place":["Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sonja","family":"T\u00f6gl","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Medical University of Vienna , Vienna,","place":["Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Karl","family":"R\u00f6ssler","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Medical University of Vienna , Vienna,","place":["Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1843-7732","authenticated-orcid":false,"given":"Christian","family":"Dorfer","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Medical University of Vienna , Vienna,","place":["Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Philippe","family":"Dodier","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Medical University of Vienna , Vienna,","place":["Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christoph","family":"H\u00f6ller","sequence":"additional","affiliation":[{"name":"Department of Dermatology, Medical University of Vienna , Vienna,","place":["Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4384-6917","authenticated-orcid":false,"given":"Rupert","family":"Bartsch","sequence":"additional","affiliation":[{"name":"Department of Medicine I, Division of Oncology, Medical University of Vienna , Vienna,","place":["Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maximilian J","family":"Hochmair","sequence":"additional","affiliation":[{"name":"Karl Landsteiner Institute of Lung Research and Pulmonary Oncology, Klinik Floridsdorf , Vienna,","place":["Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6638-3476","authenticated-orcid":false,"given":"Josa M","family":"Frischer","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Medical University of Vienna , Vienna,","place":["Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,9,1]]},"reference":[{"key":"2026100123262010900_vdag229-B1","doi-asserted-by":"publisher","first-page":"492","DOI":"10.1200\/JCO.21.02314","article-title":"Treatment for brain metastases: ASCO-SNO-ASTRO guideline","volume":"40","author":"Vogelbaum","year":"2022","journal-title":"J Clin Oncol."},{"key":"2026100123262010900_vdag229-B2","doi-asserted-by":"publisher","first-page":"48","DOI":"10.1186\/1748-717X-6-48","article-title":"Stereotactic radiosurgery for brain metastases: analysis of outcome and risk of brain radionecrosis","volume":"6","author":"Minniti","year":"2011","journal-title":"Radiation Oncology (London, England)"},{"key":"2026100123262010900_vdag229-B3","doi-asserted-by":"publisher","first-page":"387","DOI":"10.1016\/S1470-2045(14)70061-0","article-title":"Stereotactic radiosurgery for patients with multiple brain metastases (JLGK0901): a multi-institutional prospective observational study","volume":"15","author":"Yamamoto","year":"2014","journal-title":"Lancet Oncol."},{"key":"2026100123262010900_vdag229-B4","doi-asserted-by":"publisher","first-page":"289","DOI":"10.1016\/S1474-4422(05)70072-7","article-title":"Therapeutic management of brain metastasis","volume":"4","author":"Kaal","year":"2005","journal-title":"Lancet Neurol."},{"key":"2026100123262010900_vdag229-B5","doi-asserted-by":"publisher","first-page":"1480","DOI":"10.3171\/2019.1.JNS183085","article-title":"Local tumor progression treated with gamma Knife radiosurgery: differences between patients with 2-4 versus 5-10 brain metastases based on an update of a multi-institutional prospective observational study (JLGK0901)","volume":"132","author":"Serizawa","year":"2020","journal-title":"J Neurosurg."},{"key":"2026100123262010900_vdag229-B6","doi-asserted-by":"publisher","first-page":"73","DOI":"10.3171\/2010.8.GKS10994","article-title":"Analysis of radiosurgical results in patients with brain metastases according to the number of brain lesions: is stereotactic radiosurgery effective for multiple brain metastases?","volume":"113","author":"Chang","year":"2010","journal-title":"J Neurosurg."},{"key":"2026100123262010900_vdag229-B7","doi-asserted-by":"publisher","first-page":"1004","DOI":"10.1186\/s12885-023-11452-7","article-title":"Overall survival following stereotactic radiosurgery for ten or more brain metastases: a systematic review and meta-analysis","volume":"23","author":"Rozati","year":"2023","journal-title":"BMC Cancer."},{"key":"2026100123262010900_vdag229-B8","doi-asserted-by":"publisher","first-page":"34","DOI":"10.6004\/jnccn.2025.7103","article-title":"Incorporating an NCCN-based systemic therapy CNS activity score into SRS decision-making for patients with 5 or more brain metastases","volume":"24","author":"Beckham","year":"2026","journal-title":"J Natl Compr Canc Netw."},{"key":"2026100123262010900_vdag229-B9","doi-asserted-by":"publisher","first-page":"4026","DOI":"10.1002\/cam4.3021","article-title":"Toxicity and efficacy of Gamma Knife radiosurgery for brain metastases in melanoma patients treated with immunotherapy or targeted therapy-a retrospective cohort study","volume":"9","author":"Gatterbauer","year":"2020","journal-title":"Cancer Med."},{"key":"2026100123262010900_vdag229-B10","doi-asserted-by":"publisher","first-page":"352","DOI":"10.1016\/j.wneu.2016.07.038","article-title":"Evaluation of dose-staged Gamma Knife radiosurgical treatment method for High-Risk brain metastases","volume":"94","author":"Frischer","year":"2016","journal-title":"World Neurosurg."},{"key":"2026100123262010900_vdag229-B11","doi-asserted-by":"publisher","first-page":"510","DOI":"10.1016\/j.ijrobp.2007.06.074","article-title":"A new prognostic index and comparison to three other indices for patients with brain metastases: an analysis of 1,960 patients in the RTOG database","volume":"70","author":"Sperduto","year":"2008","journal-title":"Int J Radiat Oncol Biol Phys."},{"key":"2026100123262010900_vdag229-B12","doi-asserted-by":"publisher","first-page":"745","DOI":"10.1016\/s0360-3016(96)00619-0","article-title":"Recursive partitioning analysis (RPA) of prognostic factors in three radiation therapy oncology group (RTOG) brain metastases trials","volume":"37","author":"Gaspar","year":"1997","journal-title":"Int J Radiat Oncol Biol Phys."},{"key":"2026100123262010900_vdag229-B13","doi-asserted-by":"publisher","first-page":"827","DOI":"10.1001\/jamaoncol.2016.3834","article-title":"Estimating survival in patients with lung cancer and brain metastases: an update of the graded prognostic assessment for lung cancer using molecular markers (lung-molGPA)","volume":"3","author":"Sperduto","year":"2017","journal-title":"JAMA Oncol."},{"key":"2026100123262010900_vdag229-B14","doi-asserted-by":"publisher","first-page":"3668","DOI":"10.3390\/cancers12123668","article-title":"Gamma Knife radiosurgery for brain metastases in non-small cell lung cancer patients treated with immunotherapy or targeted therapy","volume":"12","author":"Cho","year":"2020","journal-title":"Cancers (Basel)"},{"key":"2026100123262010900_vdag229-B15","doi-asserted-by":"publisher","first-page":"89","DOI":"10.1023\/B:JORA.0000010892.99686.9e","article-title":"Score index for stereotactic radiosurgery of brain metastases","volume":"1","author":"Weltman","year":"1998","journal-title":"J Radiosurg"},{"key":"2026100123262010900_vdag229-B16","doi-asserted-by":"publisher","first-page":"3542","DOI":"10.3390\/cancers17213542","article-title":"Radiation necrosis in neuro-oncology: diagnostic complexity and precision radiotherapy strategies","volume":"17","author":"Mittelman","year":"2025","journal-title":"Cancers (Basel)"},{"key":"2026100123262010900_vdag229-B17","doi-asserted-by":"publisher","first-page":"76","DOI":"10.3171\/2020.11.JNS202873","article-title":"Brain tumor-related epilepsy and risk factors for metastatic brain tumors: analysis of 601 consecutive cases providing real-world data","volume":"136","author":"Asano","year":"2022","journal-title":"J Neurosurg."},{"key":"2026100123262010900_vdag229-B18","doi-asserted-by":"publisher","first-page":"e270-8","DOI":"10.1016\/S1470-2045(15)70057-4","article-title":"Response assessment criteria for brain metastases: proposal from the RANO group","volume":"16","author":"Lin","year":"2015","journal-title":"Lancet Oncol."},{"key":"2026100123262010900_vdag229-B19","doi-asserted-by":"crossref","first-page":"e260117","DOI":"10.1001\/jama.2026.0076","article-title":"Treatment for brain metastases with stereotactic radiation vs hippocampal-avoidance whole brain radiation: research summary","volume":"335","author":"Aizer","year":"2026","journal-title":"JAMA."},{"key":"2026100123262010900_vdag229-B20","doi-asserted-by":"publisher","first-page":"94","DOI":"10.1159\/000062269","article-title":"Gamma Knife radiosurgery with numerous target points for intracranially disseminated metastases","author":"Yamamoto","year":"1997","journal-title":"Radiosurgery 1997"},{"key":"2026100123262010900_vdag229-B21","doi-asserted-by":"publisher","first-page":"e479","DOI":"10.1016\/j.wneu.2020.10.124","article-title":"Stereotactic radiosurgery results for patients with 5-10 versus 11-20 brain metastases: a retrospective cohort study combining 2 databases totaling 2319 patients","volume":"146","author":"Yamamoto","year":"2021","journal-title":"World Neurosurg."},{"key":"2026100123262010900_vdag229-B22","doi-asserted-by":"publisher","first-page":"1332","DOI":"10.1016\/j.annonc.2021.07.016","article-title":"EANO-ESMO clinical practice guidelines for diagnosis, treatment and follow-up of patients with brain metastasis from solid tumours","volume":"32","author":"Le Rhun","year":"2021","journal-title":"Ann Oncol"},{"key":"2026100123262010900_vdag229-B23","doi-asserted-by":"publisher","first-page":"265","DOI":"10.1016\/j.prro.2022.02.003","article-title":"Radiation therapy for brain metastases: an ASTRO clinical practice guideline","volume":"12","author":"Gondi","year":"2022","journal-title":"Pract Radiat Oncol."},{"key":"2026100123262010900_vdag229-B24","doi-asserted-by":"publisher","first-page":"100","DOI":"10.1159\/000493055","article-title":"Guidelines for multiple brain metastases radiosurgery","volume":"34","author":"Niranjan","year":"2019","journal-title":"Prog Neurol Surg."},{"key":"2026100123262010900_vdag229-B25","doi-asserted-by":"publisher","first-page":"352","DOI":"10.1159\/000480666","article-title":"Impact of the number of metastatic tumors treated by stereotactic radiosurgery on the dose to normal brain: implications for brain protection","volume":"95","author":"Rivers","year":"2017","journal-title":"Stereotact Funct Neurosurg."},{"key":"2026100123262010900_vdag229-B26","doi-asserted-by":"publisher","first-page":"555","DOI":"10.1016\/j.adro.2017.09.002","article-title":"Single fraction stereotactic radiosurgery for multiple brain metastases","volume":"2","author":"Limon","year":"2017","journal-title":"Adv Radiat Oncol."},{"key":"2026100123262010900_vdag229-B27","doi-asserted-by":"publisher","first-page":"757","DOI":"10.1002\/cam4.1352","article-title":"The growing importance of lesion volume as a prognostic factor in patients with multiple brain metastases treated with stereotactic radiosurgery","volume":"7","author":"Routman","year":"2018","journal-title":"Cancer Med."},{"key":"2026100123262010900_vdag229-B28","doi-asserted-by":"publisher","first-page":"358","DOI":"10.1016\/j.adro.2019.11.001","article-title":"A cohort study of stereotactic radiosurgery results for patients with 5 to 15 versus 2 to 4 brain metastatic tumors","volume":"5","author":"Yamamoto","year":"2020","journal-title":"Adv Radiat Oncol."}],"container-title":["Neuro-Oncology Advances"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/noa\/advance-article-pdf\/doi\/10.1093\/noajnl\/vdag229\/70896173\/vdag229.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/noa\/article-pdf\/8\/1\/vdag229\/70896173\/vdag229.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/noa\/article-pdf\/8\/1\/vdag229\/70896173\/vdag229.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,2]],"date-time":"2026-10-02T03:26:28Z","timestamp":1790911588000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/noa\/article\/doi\/10.1093\/noajnl\/vdag229\/8778788"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1]]},"references-count":28,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2026,1,12]]}},"URL":"https:\/\/doi.org\/10.1093\/noajnl\/vdag229","relation":{},"ISSN":["2632-2498"],"issn-type":[{"value":"2632-2498","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026,1]]},"published":{"date-parts":[[2026,1]]},"article-number":"vdag229"}}