Paper Title
TWO-STAGED GAMMA KNIFE RADIOSURGERY (GKRS) FOR TREATMENT OF MORE THAN A HUNDRED BRAIN METASTASES: A CASE REPORT

Abstract
Background Surgical resection, radiotherapy, radiosurgery, immunotherapy and combinations thereof are the options for brain metastases treatment. Stereotactic radiosurgery is an alternative for patients with up to 10 brain metastases. Larger tumor volumes had been associated with side effects due to toxicity. Staged radiosurgery can reduce radiation-related side effects in the brain. Staged GKRS consists of irradiation phase, can minimize radiation side effects and improve tumor control rates. Methods A 43 years old woman with metastatic brain tumor that spreading from breast cancer presented with progressive headaches. From MRI, more than one hundred tumors were found with varying sizes ranging from 3 mm to 10 mm in diameter. Has history of received whole brain radiotherapybefore (external beam) in 15 fractions, each of2.3 Gy, with a total dose of 34.95 Gy. However, the results of radiotherapy are less than satisfactory. There was a mixed response of tumors to radiation, there were that decreased and there were that grew new. Therefore, it was decided to carry out GKRS in 2 stages. The first stage was carried out on 52 tumors with a dose of 12 Gy isodose 50%. After a break of 1 month, the second stage of GKRS was carried out on other 106 tumors with a dose of 20 Gyisodose 50%.The total number of tumors that have been irradiated were 158 tumors. Result 1 month after the first GKRS, some of the tumors had shrunk in size and some had disappeared based on MRI. Headache improvement. 1 month later after second stage of GKRS, MRI evaluation was carried out, the tumor had reduced in size and number. Clinically has improved. Conclusion Because of radiotherapy are less than satisfactory, two-stage GKRS is an effective and safe approach for the treatment of numerous brain metastasis for this patient. Nevertheless, long-term follow-up is necessary for further evaluation. Keywords - Brain Metastases, Radiotherapy, Radiosurgery, Gamma Knife