Outcomes after single-fraction preoperative stereotactic radiosurgery for brain metastases: A systematic review and meta-analysis.

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e14016 Background: Postoperative stereotactic radiosurgery (SRS) is utilized following resection of brain metastases (BM), however use is limited by target delineation uncertainty and an increased risk of leptomeningeal disease (LMD). Preoperative SRS allows for precise targeting and is being increasingly utilized in treatment paradigms of resectable BM. Reported outcomes across studies are promising and there are several phase 3 trials which are underway. Therefore, we pooled multiple studies and conducted a meta-analysis to estimate 1-year local control (LC), LMD incidence, and overall survival (OS) following single-fraction preoperative SRS for resectable BM. Methods: We systematically searched PubMed, Embase, and Scopus to identify studies of single-fraction preoperative SRS for resectable BM. For each cohort, data for 1-year LC, 1-year LMD, and 1-year OS, along with corresponding sample sizes, were extracted. A proportion-based meta-analysis was performed to derive pooled estimates and 95% confidence intervals (CIs), with between-study heterogeneity quantified using I². Results: Ten studies published between 2016 and 2025, including both prospective trials and retrospective cohorts, met the inclusion criteria. There were 617 patients treated with single-fraction preoperative SRS. The median age was 60.8 years (range 58-65 years), and the median prescribed dose was 15.8 Gy (range 14.5-17.0 Gy). The pooled 1-year LC rate was 81.9% (95% CI, 76.9-85.9; I² = 43.4%). The pooled 1-year incidence of LMD was 4.6% (95% CI, 2.8-7.4; I² = 0%), and the pooled 1-year OS rate was 60.2% (95% CI, 55.5-64.8; I² = 0%). Sensitivity analyses showed stable pooled estimates, with no single study driving the results. Conclusions: Single-fraction preoperative SRS is associated with low rates of LMD and acceptable LC and OS. In the context of historically reported postoperative SRS outcomes, these results suggest that preoperative SRS represents a promising strategy in selected patients. Randomized trials are needed to define the comparative role and optimal patient selection for preoperative SRS, with ongoing studies (NCT05341739, NCT03741673) expected to clarify its role in the management of resectable BM. Study characteristics and reported outcomes of single-fraction preoperative SRS for BM. Study Study design Number of patients Median age (years) Median dose (Gy) 1-year LTC (%) 1-year LMD (%) 1 year OS (%) Agarwal, 2024 Trial 47 59 NR NR 4.8 NR Higazy, 2025 Trial 35 61 17 82 2.86 NR Li, 2022 Retrospective 24 64 NR 87.6 NR NR Mallela, 2024 Retrospective 26 64.5 NR 77.2 NR NR Murphy, 2024 Trial 35 63 NR 76.6 NR 59 Patel, 2018 Retrospective 12 57.5 NR 49.1 10 74.1 Patel, 2016 Retrospective 66 58.2 14.5 84.1 3.2 NR Prabhu, 2025 Retrospective 124 NR 17 87.2 1.7 64.5 Prabhu, 2025

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