立体定向放射治疗在脑转移瘤治疗中的作用

目的比较全脑放疗(whole-brain Radiotherapy,WBRT)+立体定向放射治疗(stereotactic radiotherapy,SRT)和单纯WBRT对脑转移瘤的治疗效果,探讨脑转移瘤合适的治疗方法。方法将经我院明确诊断的97例脑转移瘤患者(其中肺癌53例,乳腺癌21例,其他类型肿瘤共23例)分成WBRT+SRT组和单纯WBRT组。WBRT+SRT组在全脑常规放疗(36～40Gy/3～4w)后给予SRT,4～8Gy/f,共3～6f,2次/w。WBRT组在全脑常规放疗(36～40Gy/3～4w)后缩野到局部,加量至56～60Gy/5～6w。评价两组患者脑转移瘤的局部控制率和不良反应发生情况。结果 WBRT+SRT组完全缓解率和部分缓解率分别达到了26.5%和49.0%,总有效率为75.5%,而WBRT组的完全缓解率和部分缓解率分别为16.7%和33.3%,总有效率为50.0%,二者有显著的统计学差异(P0.05)。87例放疗前有明显神经功能障碍的患者中有78人症状得到明显改善,总的有效率为89.7%,而WBRT+SRT组有效率为91.1%,WBRT组有效率为88.1%,二者无显著性差异(P0.05)。在放射治疗过程中,WBRT+SRT组中有2例(4.1%)发生了神经系统功能障碍,WBRT组中有7例(14.6%)发生了放射性相关的并发症。结论 WBRT+SRT组在脑转移瘤局部控制率方面优于WBRT组,而不良反应发生率低于WBRT组。WBRT+SRT或许是脑转移瘤比较有优势的治疗方法。     

立体定向标记标记经脑窥镜显微手术切除脑深部肿瘤

应用ＬｅｋｓｅｌｌＧ型ＣＴ立体定向仪对２６例脑深部肿瘤患者的病灶边缘进行立体定向多靶点标记,并用自行研制的自持式系列脑窥镜和目乐ＷＥＤＥＬ型手术显微镜,在小骨窗开颅条件下对上述病灶行手术显露和常规显微手术。术后２周内ＣＴ或ＭＲ扫描显示：２１例病灶完全消失,５例有少许残留,无手术死亡及昏迷、偏瘫等。认为立体定向显微镜外科手术可较为长度切除脑深部边缘不清的肿瘤;自持式脑窥镜可良好显露深部病灶,利于显微     

立体定向术治疗脑内小量出血22例疗效观察

自1999年以来,我们应用立体定向技术穿刺脑内血肿加置管引流治疗脑内小量出血患者22例,取得了显著的效果。现报告如下。     

立体定向标记经脑窥镜显微手术切除脑深部肿瘤(附26例报告)

应用ＬｅｋｓｅｌｌＧ型ＣＴ立体定向仪对２６例脑深部肿瘤患者的病灶边缘进行立体定向多靶点标记,并用自行研制的自持式系列脑窥镜和目乐ＷＥＤＥＬ型手术显微镜,在小骨窗开颅条件下对上述病灶行手术显露和常规显微手术。术后２周内ＣＴ或ＭＲ扫描显示：２１例病灶完全消失,５例有少许残留,无手术死亡及昏迷、偏瘫等。认为立体定向显微镜外科手术可较为彻底切除脑深部边缘不清的肿瘤;自持式脑窥镜可良好显露深部病灶,利于显微手术操作。     

旋转式伽玛刀治疗脑动静脉畸形254例

目的 评估旋转式伽玛刀对脑动静脉畸形(AVM)的治疗效果及术后并发症。方法 1996～2002年应用旋转式伽玛刀治疗脑AVM患者254例。AVM平均直径24mm，周边剂量平均17.7Gy，中心剂量平均35．6Gy。结果平均随访38．4个月(12～72个月)。9例患者(4．0％)伽玛刀治疗后5～21个月发生畸形血管破裂出血或再出血。225例患者治疗后行CT或MR检查，68例(30．2％)出现放射性水肿，其中6例(2．7％)遗留永久并发症。184例治疗后行脑血管造影或磁共振血管成像检查，治疗后1、2和3年的血管闭塞率分别为38．8％，71．2％和74．3％。结论旋转式伽玛刀是一种新的可靠的立体定向治疗设备，对AVM治疗后2—3年畸形血管完全闭塞率达70%以上，治疗后并发症少，且很少出现永久性并发症。     

立体 定向引导下经额切除儿童脑室内中线肿瘤

对于脑室内肿瘤,经胼胝体入路可提供清楚的解剖学标志,不破坏半球组织,因而避免了随后的运动缺损或癫痫发作的危险性。但在儿童,经胼胝体的方法可导致神经心理上的后遗症,主要涉及大脑半球的特征。作者仔细检查了借助于计算机立体定向行显微外科经额切除脑室内肿瘤的儿童,证明此方法可使手术者无需行解剖学标化,而达到位置深在的大脑病变区;在最小皮层切口情况下即可选择合适的手术路径。1 资料和方法     

大分割立体定向放射治疗用于脑转移瘤40例效果观察

目的探讨大分割立体定向放射治疗(HFSRT)脑转移瘤的临床疗效。方法对40例脑转移瘤患者行HFSRT治疗,总剂量50～65 Gy,3 Gy/d,1次/d,每周5次;或4～5 Gy/d,隔日1次,每周3次。观察近期疗效、不良反应发生情况,随访3～38个月,统计生存率。结果局部病灶有效率(CR+PR)为82.5%(33/40);不良反应(脱发、骨髓抑制、脑水肿等)多为1～2级,经支持、对症处理后均能耐受。1年生存率为45%(18/40),2年生存率为20%(8/40),3年生存率为5%(2/40)。截止到2009年11月共有38例死亡,死亡原因:颅内转移灶未控或新病灶出现及原发肿瘤复发和其他脏器转移。结论 HFSRT用于脑转移瘤近期疗效好,不良反应小,可明显延长患者生存期。     

伽玛刀治疗脑转移瘤52例临床疗效分析

脑转移瘤约占脑瘤病人的10％～15％,多有严重并发症,病人平均生存期6个月;在全身恶性肿瘤中,约有50％以上发生脑转移,目前脑转移瘤的主要治疗手段包括手术切除、放疗、化疗、X-刀及伽玛刀(γ-刀)治疗。1997年3月至2003年12月我们应用OUR—XGD旋转式γ-刀治疗脑转移瘤152例,其中单发72例,多发80例,共335个病灶,52例获得6～48个月全程随访,其中单发25例,多发27例。现将治疗结果报告如下。     

立体定向放射外科治疗脑动静脉畸形

脑动静脉畸形(AVMs)常见于青少年,主要临床症状有癫痫、出血、头痛和进展性中枢神经损害。目前外科治疗 AVMs 除手术切除和导管栓塞外,立体定向放射外科方法日益受到各国医学界重视,越来越多的 AVMs 病人接受该方法治疗。现收集近年有关文献,对此方法加以介绍。     

立体定向放疗治疗早期非小细胞肺癌

目的探讨三维适形放射治疗早期非小细胞肺癌的疗效和放射反应。方法对51例临床I～Ⅱ期非小细胞肺癌行三维适形放射治疗,年龄45～81岁,临床I期29例（T1-2NOM0）,Ⅱ期22例（T1-2N1M0）,无T3N0M0病例。病灶〈3cm33例,3—5cm4例,〉5cm4例。采用剂量体积直方图评价靶区计划,要求95％以上明W体积接受50％以上剂量,放疗剂量：小于3cm病灶,8～10Gy／次,共4～5次;3cm以上病灶,5～7Gy／次,共7～10次。照射方法：每周3次。边缘剂量控制在40Gy／10次。结果全部患者近期疗效完全缓解（CR）率62．7％（32／51）,部分缓解（PR）率31．4％（16／51）,无稳定（SD）5．9％（3／51）,进展（PD）0例。总有效率（CR＋PR）为94．2％（48／51）。肿瘤直径小于3cm,其CR率为81．8％（27／33）,3cm以上者其CR率为50．0％（9／18）,近期疗效与肿瘤大小T有关,两者差异有显著意义（r=5．78,P〈0．05）。结论立体定向放射治疗早期非小细胞肺癌是安全、有效的,具有较好的近期及远期疗效,毒副作用可耐受,失败原因主要为远处转移。     

Role of Gamma Knife Radiosurgery in Acromegaly

Stereotactic radiosurgery with the Gamma Knife allows the delivery of focused radiation in a single session from a Cobalt-60 source to a pituitary tumor with little radiation to surrounding normal brain tissue. At this time the major role for Gamma Knife radiosurgery in acromegaly is for the treatment of failed pituitary surgery although it may also by used as primary treatment for patients unwilling or unsuitable, for medical reasons, to undergo transsphenoidal surgery. The major risk from Gamma Knife radiosurgery appears to be radiation damage to the visual pathways, but this can be obviated by limiting the radiation dose to the optic chiasm under 10 Gy. In contrast, the neuronal and vascular structures running in the cavernous sinus are much less radiosensitive allowing an ablative dose to be administered to tumors showing lateral invasion and impinging on cranial nerves III, IV, V and VI. Gamma Knife radiosurgery appears to produce effects in GH secreting tumors faster than with fractionated radiotherapy without the potential long-term risk of developing a second extrapituitary brain tumor as well as the neuropsychiatric effects associated with conventional radiation administration.     

Ventralis oralis anterior (Voa) deep brain stimulation plus Gamma Knife thalamotomy in an elderly patient with essential tremor: A case report

Rationale:Deep brain stimulation (DBS) of the ventralis intermedius nucleus (Vim) provides a safe and effective therapy for medically refractory essential tremor (ET). However, DBS may be risky in elderly patients and those with ischemic brain lesions. Gamma Knife radiosurgery (GKS) is a minimally invasive procedure, but bilateral thalamotomy is dangerous.Patient concerns:We report a case of ventralis oralis anterior nucleus (Voa) DBS for dominant hand tremor plus Voa GKS for nondominant hand tremor in a very elderly patient with medically intractable ET.Diagnosis:An 83-year-old right-handed woman visited our hospital with a medically intractable ET. Because of the ischemic lesion in the right basal ganglia, we decided to perform left unilateral DBS instead of bilateral DBS.Intervention:We chose Voa as the target for DBS because, clinically, her tremor was mainly confined to her hands, and Voa had better intraoperative microelectrode recording results than Vim.Outcomes:After 2 years, her right-hand tremor remained in an improved state, but she still had severe tremor in her left hand. Therefore, we performed GKS targeting the right Voa. One year after surgery, the patient''s hand tremor successfully improved without any complications.Lessons:Salvage Voa GKS after unilateral Voa DBS is a valuable option for very elderly patients and patients with ischemic brain lesions. We suggest that Voa GKS thalamotomy is as useful and safe a surgical technique as Vim GKS for dystonic hand tremor. To the best of our knowledge, this is the first case report using salvage Voa as the only target for ET.     

Gamma knife radiosurgery for pituitary adenomas

Although surgical extirpation by transsphenoidal microsurgery is a major remedy for pituitary adenomas, adjuvant therapy also plays an important role in achieving tumor growth control and endocrine normalization in hormone-secreting tumors. Historically, the treatment options for pituitary adenomas included microsurgery, medical management, and fractionated radiotherapy, but radiosurgery has recently emerged as a practical treatment option. In this paper, we will describe the indications, radiosurgical procedure, results, histological change, and complications of gamma knife radiosurgery (GKS) for pituitary adenomas based on our experience since 1991 and a review of the literature.     

立体定向放射外科治疗硬脑膜动静脉瘘

目的评估立体定向放射外科治疗硬脑膜动静脉瘘的安全性和有效性。方法采用伽玛刀治疗硬脑膜动静脉瘘16例，其中单纯伽玛刀治疗7例，经动脉途径栓塞或手术治疗后再行伽玛刀治疗9例。根据Congard分型，硬脑膜动静脉瘘Ⅰ型4例，Ⅱa型5例，Ⅱa b型3例，Ⅲ型3例，Ⅳ型1例。靶点边缘剂量16～20Gy，平均18Gy，靶点边缘被50％～70％等剂量曲线所包含。所有患者均获得随访，随访时间为5～108个月。结果14例患者术后症状消失，2例部分改善。12例MRI或造影证实瘘口完全或近全闭塞，4例部分闭塞。无放射治疗导致的并发症。结论立体定向放射外科是一种治疗硬脑膜动静脉瘘安全、有效的方法。对侵袭型硬脑膜动静脉瘘且伴有广泛皮质静脉引流的患者，血管内治疗或手术治疗结合放射外科是一种有效的治疗模式。     

Effectiveness and Limitation of Gamma Knife Radiosurgery for Relapsed Central Nervous System Lymphoma: A Retrospective Analysis in One Institution

We describe 6 patients with relapsed central nervous system lymphoma (CNSL) treated with Gamma Knife radiosurgery (GKR). The histologic diagnosis in all 6 patients was diffuse large B-cell lymphoma without human immunodeficiency virus infection. Two patients had intracranial relapse of primary CNSL, and the remaining 4 had CNS relapse of systemic lymphoma. All patients were treated with GKR without severe adverse effects, and all but 1 patient received subsequent chemotherapy shortly after GKR. Four patients showed a complete response, and the remaining 2 patients had a partial response or stable disease. Although the neurologic symptoms disappeared or improved markedly in all patients, all of the diseases recurred or progressed 3 to 13 months after the first GKR. A second GKR was eventually performed in 4 patients. The median overall survival and progression-free survival times after the first GKR were 17 and 11 months, respectively. In our experience, GKR seems to be a useful procedure for the treatment of relapsed CNSL, because it facilitates excellent local control in a short-term treatment period without severe complications, although the efficacy period is not long enough.     

Stereotactic radiosurgery for treatment of Cushing disease: an Australian experience

Stereotactic radiation therapy has emerged as an alternative to conventional radiotherapy for treatment of Cushing disease. The aim of this study was to investigate the efficacy and safety of this treatment. Records of patients with Cushing disease treated with stereotactic radiation were reviewed. Seventeen patients underwent stereotactic radiosurgery. Ten achieved remission after a mean of 23 (95% confidence interval, 15–31) months, and two developed hormone deficiencies.     

Long-term outcomes of 170 brain arteriovenous malformations treated by frameless image-guided robotic stereotactic radiosurgery: Ramathibodi hospital experience

This study was conducted to report long-term outcomes of the frameless robotic stereotactic radiosurgery (SRS) for brain arteriovenous malformation (AVM) at Ramathibodi Hospital.Retrospective data of patients with brain AVM (bAVM), who underwent CyberKnife SRS (CKSRS) at Ramathibodi Hospital from 2009 to 2014, were examined. Exclusion criteria were insufficient follow-up time (<36 months) or incomplete information. Patients’ demographics, clinical presentation, treatment parameters, and results were analyzed. Excellent outcome was defined as AVM obliteration without a new neurological deficit. Risk factors for achieving excellent outcome were assessed.From a total of 277 CKSRS treatments for bAVM during the 6 years, 170 AVMs in 166 patients met the inclusion criteria. One hundred and thirty-nine cases (81.76%) presented with hemorrhages from ruptured bAVMs. Almost two-thirds underwent embolization before radiosurgery. With the median AVM volume of 4.17 mL, three-quarters of the cohort had single-fraction CKSRS, utilizing the median prescribed dose of 15 Gray (Gy). In the multisession group (25.29%), the median prescribed dose and the AVM volume were 27.5 Gy and 22.3 mL, respectively. An overall excellent outcome, at a median follow-up period of 72.45 months, was observed in 99 cases (58.24%). Seven AVMs (4.12%) ruptured after CKSRS but 1 patient suffered a new neurological deficit. Two patients (1.18%) were classified into the poor outcome category but there were no deaths. Negative factors for excellent outcome, by multivariate regression analysis, were the male sex and multisession SRS delivery, but not age, history of AVM rupture, previous embolization, or AVM volume.Despite relatively larger bAVM and utilizing a lower prescribed radiation dose, the excellent outcome was within the reported range from previous literature. This study offers one of the longest follow-ups and the largest cohorts from the frameless image-guided robotic SRS community.     

Re-irradiation of multiple brain metastases using CyberKnife stereotactic radiotherapy: Case report

Introduction:Brain metastasis (BM) is the commonest adult intracranial malignancy and many patients with brain metastases require two course radiotherapy. Re-irradiation is frequently performed in Radiotherapy (RT) departments for multiple brain metastases.Patient concerns:We present a case of a 55-year-old male patient suffering from brain metastases, who had previously received whole-brain radiotherapy (WBRT) and first CyberKnife Stereotactic Radiotherapy (CKSRT) for metastases, presented with a recurrence of metastasis and new lesions in the brain.Diagnoses:An enhanced computed tomography (CT) scan of the brain revealed abnormalities with double-dosing of intravenous contrast that identified >10 lesions scattered in the whole brain.Interventions:Re-irradiation was performed using CKSRT. The patient was treated with 30 Gy in 5 fractions for new lesions and 25 Gy in 5 fractions for lesion that were locally recurrent and close to brainstem lesions.Outcome:The lesions were well-controlled, and the headache of the patient was significantly relieved one month after radiotherapy. The total survival time of the patients was 17 months from the beginning of the Cyberknife treatment.Conclusion:The present case report demonstrates that CyberKnife therapy plays a significant role in the repeated radiotherapy for multiple metastatic brain tumors. CKSRT can be used as a salvage method in recurrent multiple brain metastases.     

Small cell carcinoma of the esophagus with metastasis to the brain: a case report

Small cell carcinoma of the esophagus is a rare disease with early systemic metastasis, and the prognosis remains poor. This present case (a 60-year-old Japanese man) was a small cell carcinoma at the lower third of the esophagus complicated by multiple liver and brain metastases. After the first chemotherapy, endoscopic study showed significant shrinkage of the primary esophageal tumor. About 4 months later, however, a primary tumor formed a deep ulceration, and a CT scan of the abdomen also showed further progression of the liver metastases. One year after starting the therapy, a disturbance in the patient’s right eyesight and awkward movement of his right hand occurred. Brain magnetic resonance imaging revealed several high-density areas compatible with metastasis. Gamma knife radiosurgery for metastatic brain tumors was carried out, and all tumors had shrunk. Unfortunately, the patient’s liver function deteriorated gradually because of the aggravation of liver metastases, and the patient died 1 year and 5 months from the time of diagnosis.     

Local ablative therapy of brain metastasis from non-small cell lung cancer: benefits and limitations

Brain metastases (BMs) are the most common intracranial tumors and non-small cell lung cancer (NSCLC) are responsible for BM more than any other solid tumor. Its frequency is increasing due to of the availability of new imaging techniques, earlier diagnosis and improvement in treatment techniques and survival rates. NSCLC patients with BM represent heterogeneous prognostic group. The possibility of better prognostic stratification associated with more systemic therapy options and imaging and radiation technology advances have led to an increment of evaluation and indication of local ablative radiotherapy. The definite increment in quality of life and the potential overall survival (OS) benefit of its indication must be balanced with eventual higher risk of brain disseminated disease when whole brain irradiation is postponed. Therefore, a multidisciplinary evaluation is recommended to refine and personalize the therapeutic approach. The development of clinical nomograms or evaluation of circulating tumor cells/tumoral DNA that predict the survival free of new lesions may be the tools that will warranty further optimization of the treatment of NSCLC patients with BM. In this review, we report the main aspects of diagnosis, prognosis and therapeutic options and dilemmas evolving local ablative radiotherapy essentially based on seminal, updated prospective studies and ongoing trials.