Pre-operative stereotactic radiosurgery versus intraoperative cesium-131 brachytherapy for resected brain metastases: a systematic review and meta-analysis.

Overview

1. Department of Neurosurgery, Allegheny Health Network Neuroscience Institute, 320 E North Ave, Pittsburgh, PA 15212 USA
2. Drexel University College of Medicine, Philadelphia, PA USA
3. Edward Via College of Osteopathic Medicine, Carolinas Campus, Spartanburg, SC USA
4. Department of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA USA
5. Department of Neurosurgery, University of Louisville, Louisville, KY USA

Abstract

Background: Pre-operative stereotactic radiosurgery (SRS) and intraoperative cesium-131 (Cs-131) brachytherapy are alternatives to post-operative SRS for resected brain metastases (BMs). The randomized phase 3 Radiation One and Done Study (ROADS; NCT04365374) showed improved surgical-bed control with Cs-131 tiles versus post-operative stereotactic radiotherapy, but outcomes relative to pre-operative SRS are undefined.

Methods: PubMed, Embase, and ScienceDirect were searched through October 2026 (PRISMA 2020); one further trial was identified by other methods. Twelve-month local control (LC), leptomeningeal disease (LMD), radiation necrosis (RN), and overall survival (OS) were extracted for treatment-naïve BMs. Proportions were pooled with random-effects generalized linear mixed models and compared with a test for subgroup differences; sensitivity analyses included meta-regression, Hartung–Knapp, leave-one-out, follow-up, and fractionation analyses.

Results: Fifteen pre-operative SRS studies (918 patients/940 BMs) and four brachytherapy studies (207 patients/217 BMs) were included. Pooled 12-month LC was 97% (95% CI 90–99) with Cs-131 brachytherapy and 90% (86–93) with pre-operative SRS (test for subgroup differences p = 0.054; meta-regression p = 0.019; Hartung–Knapp p = 0.066); among studies reporting observed counts, LC was 99% vs. 90% (p = 0.009). Within pre-operative SRS, LC was 96% after hypofractionated and 86% after single-fraction treatment (p = 0.005). LMD (9.1% vs. 5.1%) and RN (0.7% vs. 5.2%) did not differ significantly. Median OS was 15.6 months with brachytherapy (range 5.9–42.5; 11.0 months, range 5.9–20.1, excluding the ROADS estimate) and 14.4 months with pre-operative SRS (range 6.3–26.4).

Conclusion: Both approaches achieved high LC with low rates of LMD and RN. There was a trend towards higher LC with Cs-131 brachytherapy than with pre-operative SRS (97% vs. 90%; p = 0.054), and significantly so among studies reporting observed counts (99% vs. 90%; p = 0.009). Hypofractionated pre-operative SRS achieved LC similar to that of brachytherapy, suggesting that the difference may reflect single-fraction dose de-escalation rather than an intrinsic advantage of either modality. The two techniques may serve complementary roles, and prospective comparative study is warranted.

Registration: This review was not registered in PROSPERO.

Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1007/s11060-026-05870-3.

Reproduced under the paper's license (CC BY), from the paper cited above.

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This paper

Kite, T., Mahmoudi, D. A., Singh, E., Knox, H., Gupta, B., Whiting, A. C., Karlovits, S., Wegner, R. E., Williams, B., & Shepard, M. J. (2026). Pre-operative stereotactic radiosurgery versus intraoperative cesium-131 brachytherapy for resected brain metastases: a systematic review and meta-analysis. Journal of neuro-oncology, 180(2), 40. https://doi.org/10.1007/s11060-026-05870-3

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