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In another study of 10 patients with HER2+ BCBM treated with SRS combined with dual-targeted therapy (trastuzumab and pertuzumab) observed no local progression after a median follow-up of 18.3 months, achieved a mOS of 33.9 months, and reported only a single case of asymptomatic RN (127).While earlier ADCs such as T-DM1 were associated with an increased risk of RN when combined with SRT (128, 129), a study of the newer agent trastuzumab deruxtecan (T-DXd) reported a 97% 1-year ILC with only 1% symptomatic RN in 215 treated lesions, supporting its superior intracranial activity and more favorable safety profile (130, 131)