We report on a 64-year-old woman who initially presented to the emergency department with complaints of chest pain following a motor vehicle crash. A CT incidentally found renal abnormalities, and a postnephrectomy biopsy confirmed renal cell carcinoma. The patient was asymptomatic at that time and remained so for ten months, after which she visited her primary care physician with complaints of mild intermittent headaches and difficulty with balance. An MRI revealed five cerebellar lesions measuring 1.4 × 1.5 × 1.6 cm, 2.0 × 1.5 × 1.7 cm, 0.7 × 0.7 × 0.7 cm, 0.2 × 0.2 × 0.2 cm, and 0.1 × 0.1 × 0.1 cm, as well as extensive vasogenic edema.\nHer treatment team recommended against resection due to the sensitive location of her tumors. GKRS was recommended over WBRT due to concern that avoiding previous radiation fields from treatment for oropharyngeal carcinoma 14 years earlier would not adequately address her relatively caudal metastatic tumors. The patient then underwent her first GKRS treatment at a dose of 22 Gy at the 50% isodose line (Figures and ). On the day of treatment, her Karnofsky Performance Status score was 100. Following GKRS, she was placed on dexamethasone 2 mg daily. Within several weeks she had experienced significant resolution of symptoms.\nOver the next 51 months, she underwent a subsequent six GKRS treatments, all of which treated between one and four metastases. Many of these metastases were in new locations within the cerebellum, while several appeared in the brainstem itself. 49 months after her initial treatment, she underwent a craniotomy to relieve obstructive hydrocephalus with a ventricular shunt placement. An 8.0 mm cerebellar lesion was successfully resected in the same procedure. Around the same time, she underwent SBRT for liver metastases, which was tolerated well.\nThe patient's most recent GKRS treatment occurred 60 months after the first and was suggested when the patient presented with complaints of consistent falls. A CT demonstrated five lesions, four of which were localized to the cerebellum and one limited to the pons. Three of the lesions had increased in size since her previous CT several months earlier. Three lesions were treated with a dose of 20 Gy at the 50% isodose line, one lesion was treated with 18 Gy at the 75% isodose line, and one was treated with 18 Gy at the 55% isodose line. A posttreatment CT demonstrated reduced dimensions of all lesions. Her most recent CT was taken 5 months later and demonstrated reduced or stable sizes of all lesions. 65 months after her initial diagnosis of brain metastasis, the patient began treatment with Votrient 800 mg for her liver metastases, which was tapered down to 400 mg and eventually held completely for after severe GI side effects and elevated liver enzymes.\nOne month prior to this paper, a PET scan was obtained, showing no new evidence of systemic or metastatic disease. At that time, she remained symptom-free with a high quality of life a total of 72 months after her brain metastases were diagnosed.
A 75-year-old man was diagnosed in June 2016 with right-sided pleural desmoplastic mesothelioma. He had a previous history of smoking and exposure to asbestos as well as substantial underlying cardiovascular comorbidity. Curative treatment was deemed not feasible. While awaiting palliative antitumoral treatment, the patient experienced impaired balance, severe rotational vertigo, nausea, and vomiting. Brain CT and MRI in July 2016 revealed a solitary 20-mm metastasis with slight surrounding edema in the left middle cerebellar peduncle and extending along the tentorium (M1). V4 was minimally compressed without hydrocephalus. Corticosteroid therapy was initiated but microsurgery was deemed not feasible due to previous cardiovascular morbidity. Systemic palliative chemotherapy was initiated and he was referred for GKRS as no other treatment options remained available for M1. The patient underwent 3R-intervention for his solitary lesion in August 2016. KPS was estimated as 70–80 and RPA as 2 at GKRS 1 during steroid treatment de-escalation. KPS subsequently improved to 80 at GKRS 2 and 90–100 at GKRS 3 despite decreased steroid dose. M1 underwent a volume reduction of 22% between GKRS 1 and GKRS 3 (10.2 cm3 to 7.9 cm3) while V4 volume increased from 0.79 cm3 to 0.93 cm3 (21%). One-month follow-up with clinical assessment and MRI revealed mild fatigue presumed due to ongoing systemic antitumoral treatment (KPS 90) though without major neurological impairment, and substantial tumor volume reduction of almost 50% (10.2 cm3 at GKRS 1 to 5.6 cm3 at 4 weeks after GKRS 3). V4 volume had also increased significantly (from 0.79 cm3 at GKRS 1 to 1.31 cm3 at 4 weeks) []. A follow-up MRI at 3 months showed a small suspected recurrence with mild surrounding edema at the inferior aspect of the previous radiation field which was successfully treated in December 2016 along with ten new metastases; all eleven lesions were treated with SF-GKRS. No clinical signs of neurological deficits or radiological evidence of ARE were reported. The patient died 6 months after completion of 3R due to an aggressive, drug-resistant pneumonia.