***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: PURPOSE A phase I dose escalation of hypofractionated stereotactic radiotherapy ( H-SRT ) in recurrent or persistent malignant gliomas as a means of increasing the biologically effective dose and decreasing the high rate of reoperation due to toxicity associated with single-fraction stereotactic radiosurgery ( SRS ) and brachytherapy . MATERIAL S AND METHODS From November 1994 to September 1996 , 25 lesions in 20 patients with clinical and /or imaging evidence of malignant glioma persistence or recurrence received salvage H-SRT . Nineteen patients at the time of initial diagnosis had glioblastoma multiforme ( GBM ) and one patient had an anaplastic astrocytoma . All of these patients with tumor persistence or recurrence had received initial fractionated radiation therapy ( RT ) with a mean and median dose of 60 Gy ( 44.0 - 72.0 Gy ) . The median time from completion of initial RT to H-SRT was 3.1 months ( 0.7 - 45.5 months ) . Salvage H-SRT was delivered using daily 3.0 - 3.5 Gy fractions ( fxs ) . Three different total dose levels were sequentially evaluated : 24.0 Gy/3.0 Gy fxs ( five lesions ) , 30.0 Gy/3.0 Gy fxs ( 10 lesions ) , and 35.0 Gy/3.5 Gy fxs ( nine lesions ) . Median treated tumor volume measured 12.66 cc ( 0.89 - 47.5 cc ) . The median ratio of prescription volume to tumor volume was 2.8 ( 1.4 - 5.0 ) . Toxicity was judged by RTOG criteria . Response was determined by clinical neurologic improvement , a decrease in steroid dose without clinical deterioration , and /or radiologic imaging . RESULTS No grade 3 toxicities were observed and no reoperation due to toxicity was required . At the time of analysis , 13 of 20 patients had died . The median survival time from the completion of H-SRT is 10.5 months with a 1-year survival rate of 20 % . Neurological improvement was found in 45 % of patients . Decreased steroid requirements occurred in 60 % of patients . Minor imaging response was noted in 22 % of patients . Using Fisher 's exact test , response of any kind correlated strongly to total dose ( p = 0.0056 ) . None of six lesions treated with 21 Gy or 24 Gy responded , whereas there was a 79 % response rate among the 19 lesions treated with 30 or 35 Gy . Tumor volumes < or = 20 cc were associated with a higher likelihood of response ( p = 0.053 ) . CONCLUSIONS H-SRT used in this cohort of previously irradiated patients with malignant glioma was not associated with the need for reoperation due to toxicity or grade 3 toxicity . This low toxicity profile and encouraging H-SRT dose-related response outcome justifies further evaluation and dose escalation The purpose of this study was to retrospectively evaluate the survival of patients with high- grade gliomas treated with external beam radiotherapy with or without radiosurgical boost . From July 1993 to April 1998 , 32 patients were selected , 15 of which received radiosurgery . Inclusion criteria were age > 18 years , histological confirmation of high- grade glioma , primary tumor treatment with curative intent , unifocal tumor and supratentorial location . All patients were found to be in classes III – VI , according to the recursive partitioning analysis proposed by the Radiation Therapy Oncology Group . The median interval between radiotherapy and radiosurgery was 5 weeks ( range 1–13 ) . Treatment volumes ranged from 2.9 to 70.3 cc ( median 15.0 cc ) . Prescribed  radiosurgery doses varied from 8.0 to 12.5 Gy ( median 10.0 Gy ) . Radiosurgery and control groups were well balanced with respect to prognostic factor distributions . Median actuarial survival time in radiosurgery and control groups was 21.4 months and 11.6 months , respectively ( p=0.0254 ) . Among patients with KPS≥80 , median survival time was 11.0 months and 53.9 months in the control and radiosurgery groups , respectively ( p=0.0103 ) . Radiosurgery was the single factor correlated with survival on Cox model analysis ( p=0.0362 ) and was associated with a 2.76 relative reduction in the risk of cancer death ( 95 % confidence interval ( CI ) 1.07–7.13 ) . Our results suggest that radiosurgery may confer a survival advantage for patients in RPA classes III – VI , especially for those with Karnofsky performance status ≥80 . The definitive role of radiosurgical boost for patients with high- grade gliomas awaits the results of r and omized trials Background . The treatment of recurrent gliomas is palliative ; however , the local pattern of tumor recurrence permits retreatment with single fraction , high dose stereotactic radiotherapy or radiosurgery ( RS ) . Twenty-two patients with recurrent glioma have been treated on a dose escalation protocol with fractionated stereotactic external beam radiotherapy ( SRT ) . All had previously received radical radiotherapy ( median dose 55 Gy ) as part of the initial treatment . The dose of SRT was increased from 30 Gy in six fractions to 50 Gy in ten fractions . Median survival from the date of SRT was 9.8 months . There was no significant acute morbidity but five patients who received > or = 40 Gy developed steroid responsive neurological deterioration assumed to represent late radiation damage . The survival and toxicity in patients with recurrent glioma are comparable with interstitial therapy . Fractionated SRT is a noninvasive form of localised radiation which may be a suitable alternative to interstitial therapy in this group of patients In a non-r and omised study in six centres in the UK , 24 patients with previously untreated small-cell lung cancer of limited extent were treated with a regimen of alternating chemotherapy and radiotherapy to assess response , toxicity , and the feasibility of applying such a regimen on a multicentre basis in the UK . The intention was to give six courses of chemotherapy on five consecutive days at 4-week intervals : etoposide 75 mg m-2 on days 1 , 2 , and 3 ; doxorubicin 40 mg m-2 on day 1 ; cisplatin 100 mg m-2 on day 2 ; and cyclophosphamide 300 mg m-2 on days 2 , 3 , 4 and 5 . A dose of 20 Gy thoracic radiotherapy was to be given following the 2nd and the 3rd courses , and one of 15 Gy following the 4th course . After 12 patients had been admitted , the cisplatin dosage was reduced to 80 mg m-2 because of unacceptable toxicity . Two patients were withdrawn during treatment on review of their histology because their diagnosis was found to be incorrect . Only one patient of the 12 treated with cisplatin 100 mg m-2 was able to complete treatment , compared with five of the eligible ten given the lower dosage . Among the 22 patients with confirmed small-cell disease , a complete response was reported in 14 ( 64 % ) and a partial response in a further three ( total response rate 77 % ) . Myelosuppression was the commonest serious adverse effect . It occurred in 19 of the 24 patients and gave rise to septicaemia in five , four of whom were receiving the higher cisplatin dose . Sixteen patients required blood transfusion and ten platelet transfusion . Vomiting , oesophagitis , and peripheral neuropathy occurred in 12 , four and four patients , respectively , and radiation pneumonitis developed in two . Treatment was considered a contributory cause of death in four . The working party concluded that the alternating regimen was feasible in only a small proportion of centres in the UK , and decided not to embark on a multicentre r and omised trial comparing alternating with conventional scheduling Despite the progress in neurosurgery and radiotherapy , almost all patients treated with malignant gliomas develop recurrent tumors and die of their disease . Eighty-eight patients ( median age 56 years ) with recurrent glioblastoma ( median tumor volume 32.7 cm3 ) were treated with noninvasive fractionated stereotactic radiosurgery and concurrent paclitaxel used as a sensitizer . The median interval between diagnosis of primary glioblastoma and salvage radiosurgery was 7.8 months . Four weekly treatments ( median dose : 6.0 Gy ) were delivered after the 3-hour paclitaxel infusion ( median dose : 120 mg/m2 ) . Survival was calculated by the Kaplan-Meier method from radiosurgery treatment . Overall median survival was 7.0 months , and the 1-year and 2-year actuarial survival rates were 17 % and 3.4 % , respectively . When grouped by performance status , there was no difference in survival between the patients with low and high Karnofsky score . Patients with tumor volume less than 30 cm3 survived significantly longer than those with tumor greater than 30 cm3 ( 9.4 vs. 5.7 months , p = 0.0001 ) . Their 1-year survival rate was 40 % and 8 % , respectively . Eleven patients ( 11 % ) had reoperation because of exp and ing mass . Stable disease was seen in 40 % of patients ( n = 34 ) , and increase in radiographically detected mass was observed in 41 patients ( 48.8 % ) . Although the treatment of recurrent GBM is mostly palliative , the fractionated radiosurgery offers a chance for prolonged survival , especially in patients with a smaller tumor volume PURPOSE The purpose is twofold : ( 1 ) to identify the malignant glioma patients treated in a trial of hyperfractionated radiotherapy ( RT ) and carmustine ( BCNU ) who may have been eligible for a stereotactic radiosurgery ( SRS ) boost ;  and ( 2 ) to compare survival of such patients with that of those considered SRS-ineligible . PATIENTS AND METHODS From January 1983 to July 1989 , 778 malignant glioma patients were enrolled on Radiation Therapy Oncology Group ( RTOG ) 83 - 02 , a r and omized phase I/II hyperfractionated RT dose-escalation trial with BCNU chemotherapy .  The SRS criteria used in a single-institution trial were applied to these patients ; they are : Karnofsky performance status ( KPS ) of greater than 60 ; well-circumscribed tumor less than 4.0 cm ; no subependymal spread ; and a location not adjacent to brainstem or optic chiasm . RESULTS Eighty-nine patients ( 11.9 % ) were identified as potentially SRS-eligible . The median survival times ( MST ) and 18-month survival rates of the 89 eligible and 643 ineligible patients were 14.4 versus 11.7 months and 40 % versus 27 % , respectively ( P = .047 ) . The MST and 18-month survival rate of the 544 SRS-ineligible patients with KPS greater than 60 were 12.1 months and 29 % , respectively , and were not statistically inferior to the survival of the SRS-eligible group ( P = .21 ) . Multivariate analysis revealed age , KPS , and histopathology to be strongly predictive of survival , and SRS eligibility was also significantly predictive ( P = .047 ) . CONCLUSION SRS-eligible patients enrolled on RTOG 83 - 02 had survival superior to that of the SRS-ineligible group , and this advantage is mainly due to the selection of a subgroup with a high minimum KPS OBJECT After conventional doses of 55 to 65 Gy of fractionated irradiation , glioblastoma multiforme ( GBM ) usually recurs at its original location . This institutional phase II study was design ed to assess whether dose escalation to 90 cobalt gray equivalent ( CGE ) with conformal protons and photons in accelerated fractionation would improve local tumor control and patient survival . METHODS Twenty-three patients were enrolled in this study . Eligibility criteria included age between 18 and 70 years , Karnofsky Performance Scale score of greater than or equal to 70 , residual tumor volume of less than 60 ml , and a supratentorial , unilateral tumor .  Actuarial survival rates at 2 and 3 years were 34 % and 18 % , respectively . The median survival time was 20 months , with four patients alive 22 to 60 months postdiagnosis . Analysis by Radiation Therapy Oncology Group prognostic criteria or Medical Research Council indices showed a 5- to 11-month increase in median survival time over those of comparable conventionally treated patients . All patients developed new areas of gadolinium enhancement during the follow-up period . Histological examination of tissues obtained at biopsy , resection , or autopsy was conducted in 15 of 23 patients . Radiation necrosis only was demonstrated in seven patients , and their survival was significantly longer than that of patients with recurrent tumor ( p = 0.01 ) . Tumor regrowth occurred most commonly in areas that received doses of 60 to 70 CGE or less ; recurrent tumor was found in only one case in the 90-CGE volume . CONCLUSIONS A dose of 90 CGE in accelerated fractionation prevented central recurrence in almost all cases . The 
    Output:
    
There is a lack of evidence of survival advantages to use this treatment at the time of diagnosis or relapse .
There is also insufficient evidence regarding the benefice/harms in the use of stereotactic fractionated radiation therapy for patients with glioma .
Stereotactic irradiation as boost in primary diagnosed glioma or relapsed tumour is not associated with survival improvement .