Local control and toxicity after stereotactic radiotherapy in brain metastases patients and the impact of novel systemic treatments

•Systemic treatment combined with radiotherapy provides better local control.•Toxicity was not increased in patients using immunotherapy or targeted therapy.•Chemotherapy and targeted therapy were shortly discontinued around irradiation.•Large brain metastasis diameter does not affect local control; does affect toxicity. Treatment modalities for patients with brain metastases consist of surgery, radiotherapy, and systemic treatments such as immunotherapy and targeted therapy. Although much is known about local control of brain metastases after radiotherapy and surgery alone, more understanding is needed of the additional effect of new systemic treatments. Our study presents real-world data about the combined effects of different local and systemic treatment strategies on local response of irradiated brain metastases. We performed a retrospective consecutive cohort study of patients that presented with brain metastases in our institution between June 2018 and May 2020, reporting the impact of radiotherapy alone versus radiotherapy combined with systemic treatment on local control of irradiated brain metastases and toxicity. Chemotherapy and targeted therapy were temporarily discontinued around irradiation. 262 consecutively treated patients were included in the study. Median time to local failure of irradiated brain metastases was 18 months (IQR 9–34), median overall survival was 20 months (IQR 10–36). 211 (81 %) patients received systemic treatment. Patients with breast cancer had a worse local control (HR 2.3, 95 % CI 1.0–5.0, p = 0.038), as did patients without any systemic treatment (HR 2.1, 95 % CI 1.1–4.3, p = 0.034). Symptomatic radiation necrosis occurred in 36 (14 %) patients. A diameter > 2.5 cm was associated with a higher risk of radiation necrosis. No association was found between systemic treatment in combination with local radiotherapy and symptomatic radiation necrosis. Patients who received any form of systemic treatment had better local control after stereotactic radiosurgery for brain metastases. We did not find an association between systemic treatment and the incidence of radiation necrosis.