Stereotactic radiosurgery alone versus resection plus whole-brain radiotherapy for 1 or 2 brain metastases in recursive partitioning analysis class 1 and 2 patients

BACKGROUND: The objective of this study was to compare stereotactic radiosurgery (SRS) alone with resection plus whole-brain radiotherapy (WBRT) for the treatment of patients in recursive partitioning analysis (RPA) class 1 and 2 who had 1 or 2 brain metastases. METHODS: Two hundred six patients in RPA class 1 and 2 who had 1 or 2 brain metastases were analyzed retrospectively. Patients in Group A (n = 94) received from 18 grays (Gy) to 25 Gy SRS, and patients in Group B (n = 112) underwent resection of their metastases and received 10 x 3 Gy/20 x 2 Gy WBRT. Eight other potential prognostic factors were evaluated regarding overall survival (OS), brain control (BC), and local control (LC) of treated metastases: age, sex, performance status, tumor type, number of brain metastases, extracranial metastases, RPA class, and interval from tumor diagnosis to treatment of brain metastases. RESULTS: A comparison of the 2 treatment groups did not reveal significantly different OS (P = .19), BC (P = .52), or LC (P = .25). In RPA subgroup analyses, outcome also did not differ significantly for either RPA class of patients (P values from .21 to .83). On multivariate analysis, improved OS was associated with age < or =60 years (relative risk [RR], 1.75; P = .002), better performance status (RR, 1.67; P = .015), no extracranial metastases (RR, 2.84; P < .001), interval from tumor diagnosis to treatment >12 months (RR, 1.70; P = .003), and RPA class 1 (RR, 1.51; P = .016). Improved BC was associated with a single metastasis (RR, 1.54; P = .034) and an interval from tumor diagnosis to treatment >12 months (RR, 1.58; P = .019), and improved LC was associated with an interval from tumor diagnosis to treatment >12 months (RR, 1.59; P = .047). CONCLUSIONS: SRS alone appeared to be as effective as resection plus WBRT in the treatment of 1 or 2 brain metastases for patients in RPA class 1 and 2. Patient outcomes were associated with age, Karnofsky performance status, number of brain metastases, extracranial metastases, RPA class, and interval from tumor diagnosis to treatment.     

A boost in addition to whole-brain radiotherapy improves patient outcome after resection of 1 or 2 brain metastases in recursive partitioning analysis class 1 and 2 patients

BACKGROUND: The current study was conducted to compare 2 treatment regimens including surgical resection and whole-brain radiotherapy (WBRT) for patients with 1 to 2 brain metastases. METHODS: A total of 201 patients with recursive partitioning analysis (RPA) class 1 to 2 disease with 1 to 2 resectable brain metastases were analyzed retrospectively. Patients underwent either resection of the metastases plus WBRT with 10 fractions of 3 grays (Gy) each or 20 fractions of 2 Gy each (99 patients; Group A) or the same treatment plus a WBRT boost to the metastatic site (10 fractions of 3 Gy each plus 5 fractions of 3 Gy each or 20 fractions of 2 Gy each plus 5 fractions of 2 Gy each) (102 patients; Group B). Eight other potential prognostic factors were evaluated with regard to overall survival (OS), brain control (BC), and local control of resected metastases (LC): age, gender, Karnofsky performance status, extent of surgical resection, tumor type, extracranial metastases, RPA class, and interval from tumor diagnosis to WBRT. RESULTS: Group B patients had better 1-year OS (66% vs 41%; P < .001). On multivariate analysis of OS, treatment regimen (relative risk [RR] of 1.94; P < .001), extent of surgical resection (RR of 1.80; P = .001), and interval from tumor diagnosis to WBRT (RR of 1.62; P = .010) were found to be statistically significant. On multivariate analysis of BC, treatment regimen (RR of 2.15; P = .002), extent of surgical resection (RR of 2.78; P < .001), and interval from tumor diagnosis to WBRT (RR of 1.52; P = .034) were found to be statistically significant. On multivariate analysis of LC, treatment regimen (RR of 2.31; P = .002) and extent of surgical resection (RR of 3.79; P < .001) were found to be statistically significant. On RPA class subgroup analyses, outcome was found to be significantly better with a WBRT boost in both RPA class 1 and class 2 patients. A WBRT boost resulted in better outcome after both complete and incomplete surgical resection. However, the results concerning BC and LC were not found to be statistically significant if surgical resection was incomplete. CONCLUSIONS: After surgical resection of 1 to 2 brain metastases, a boost of 10 to 15 Gy in addition to WBRT was found to improve outcome. After incomplete surgical resection, further dose escalation to the metastatic site may be considered.     

Evaluation of 2 whole-brain radiotherapy schedules and prognostic factors for brain metastases in breast cancer patients

BACKGROUND: The majority of breast cancer patients with brain metastases receive whole-brain radiotherapy (WBRT) and have a survival of only a few months. A short WBRT regimen would be preferable if it provides survival that is similar to that achieved with longer programs. This retrospective study compared survival and local control within the brain resulting from short-course WBRT with longer programs in 207 breast cancer patients. METHODS: Sixty-nine patients treated with 5 fractions of 4 grays (Gy) each given within 5 days were compared with 138 patients treated with 10 fractions of 3 Gy each given over 2 weeks or 20 fractions of 2 Gy each given over 4 weeks. Six additional potential prognostic factors were investigated: age, Karnofsky performance score (KPS), number of brain metastases, the presence of extracranial metastases, interval from tumor diagnosis to WBRT, and recursive partitioning analysis (RPA) class. RESULTS: On univariate analysis, the WBRT regimen was not found to be associated with survival (P=.254) or local control (P=.397). Improved survival was associated with a KPS>70 (P<.001), single brain metastasis (P=.023), the absence of extracranial metastases (P<.001), and lower RPA class (P<.001). On multivariate analysis, which was performed without RPA class because this is a confounding variable, KPS (relative risk [RR] of 4.00; P<.001) and the presence of extracranial metastases (RR of 1.54; P=.024) maintained statistical significance. On univariate analysis, local control was associated with KPS (P<.001) and RPA class (P<.001). On multivariate analysis, local control was found to be associated with a KPS>70 (RR of 5.75; P<.001). CONCLUSIONS: Short-course WBRT with 5 fractions of 4 Gy each resulted in survival and local control that were similar to longer programs in breast cancer patients with brain metastases. The dose of 5 fractions of 4 Gy each appears preferable for the majority of these patients because it is less time consuming and more convenient.     

Two radiation regimens and prognostic factors for brain metastases in nonsmall cell lung cancer patients

BACKGROUND: Nonsmall cell lung cancer (NSCLC) patients with brain metastases usually receive whole-brain radiotherapy (WBRT). Most of these patients survive for only a few months. A short course of WBRT would be preferable to longer regimens if it could provide similar survival. This retrospective study of NSCLC patients compared longer treatment programs with short-course WBRT with 5 x 4 Gy given during 5 days. METHODS: Data from 404 NSCLC patients treated with WBRT for brain metastases were retrospectively analyzed. The 140 patients who received 5 x 4 Gy given in 5 days were compared for survival with 264 patients who received either 10 x 3 Gy given in 2 weeks or 20 x 2 Gy given in 4 weeks. Seven further potential prognostic factors were investigated for survival including age, sex, Karnofsky performance score (KPS), number of brain metastases, extracranial metastases, interval from tumor diagnosis to WBRT, and RPA (recursive partitioning analysis) class. RESULTS: The WBRT regimen was not associated with survival (P = .55). On multivariate analysis, age < 60 years (vs > or =60 years, P = .020), KPS > or =70 (vs KPS < 70, P < .001), interval from tumor diagnosis to WBRT > 12 months (vs < or =12 months, P = .007), no extracranial metastases (P < .001), and RPA class 1 (vs RPA class 2 vs RPA class 3, P = .007) were significantly associated with improved survival. CONCLUSIONS: Short-course WBRT with 5 x 4 Gy appeared preferable for most NSCLC patients, as it was associated with survival similar to longer WBRT programs, and the short course was less time consuming.     

全脑放疗对广泛期小细胞肺癌脑转移的生存影响北大核心CSCD

目的探索现代诊疗条件下,全脑放疗(WBRT)能否延长小细胞肺癌(SCLC)脑转移患者的生存期。方法回顾性分析天津医科大学肿瘤医院2010—2020年245例伴有脑转移的广泛期SCLC患者的病历资料,其中WBRT组168例(剂量30 Gy分10次),无WBRT组77例。所有患者均接受了至少2个周期的化疗,化疗方案均为顺铂或卡铂联合依托泊苷,115例接受了胸部放疗。研究终点为脑转移后生存期(BM-OS),采用卡方检验对分类数据进行比较,采用稳健逆概率处理加权(sIPTW)方法对组间变量进行匹配,采用Kaplan-Meier方法进行生存分析,log-rank检验进行生存曲线比较。结果全组患者中位BM-OS为9.1个月。有无WBRT患者的中位BM-OS分别为10.6、6.7个月(P=0.003),应用sIPTW平衡两组影响因素后,两组的BM-OS差异仍具有统计学意义(P=0.02)。其中,首诊广泛期伴脑转移患者118例,有无WBRT的中位BM-OS分别为13.0、9.6个月(P=0.007);广泛期疗中出现脑转移患者127例,有无WBRT的中位BM-OS分别为8.0、4.1个月(P=0.003)。在50例单纯脑转移患者中,有无WBRT的中位BM-OS为13.3、10.9个月(P=0.259);在195例伴有颅外转移的患者中,有无WBRT的中位BM-OS分别为9.5、5.9个月(P=0.009)。结论广泛期小细胞肺癌脑转移患者行全脑放疗能够为患者带来生存获益。     

全脑放疗对广泛期小细胞肺癌脑转移的生存影响

目的 探索现代诊疗条件下,全脑放疗（WBRT）能否延长小细胞肺癌（SCLC）脑转移患者的生存期。方法 回顾性分析天津医科大学肿瘤医院2010—2020年245例伴有脑转移的广泛期SCLC患者的病历资料,其中WBRT组168例（剂量30 Gy分10次）,无WBRT组77例。所有患者均接受了至少2个周期的化疗,化疗方案均为顺铂或卡铂联合依托泊苷,115例接受了胸部放疗。研究终点为脑转移后生存期（BM‐OS）,采用卡方检验对分类数据进行比较,采用稳健逆概率处理加权（sIPTW）方法对组间变量进行匹配,采用Kaplan‐Meier方法进行生存分析,log‐rank检验进行生存曲线比较。结果 全组患者中位BM‐OS为9.1个月。有无WBRT患者的中位BM‐OS分别为10.6、6.7个月（P=0.003）,应用sIPTW平衡两组影响因素后,两组的BM‐OS差异仍具有统计学意义（P=0.02）。其中,首诊广泛期伴脑转移患者118例,有无WBRT的中位BM‐OS分别为13.0、9.6个月（P=0.007）;广泛期疗中出现脑转移患者127例,有无WBRT的中位BM‐OS分别为8.0、4.1个月（P=0.003）。在50例单纯脑转移患者中,有无WBRT的中位BM‐OS为13.3、10.9个月（P=0.259）;在195例伴有颅外转移的患者中,有无WBRT的中位BM‐OS分别为9.5、5.9个月（P=0.009）。结论 广泛期小细胞肺癌脑转移患者行全脑放疗能够为患者带来生存获益。     

A meta-analysis evaluating stereotactic radiosurgery, whole-brain radiotherapy, or both for patients presenting with a limited number of brain metastases

BACKGROUND:

To perform a meta‐analysis on newly diagnosed brain metastases patients treated with whole‐brain radiotherapy (WBRT) and stereotactic radiosurgery (SRS) boost versus WBRT alone, or in patients treated with SRS alone versus WBRT and SRS boost.

METHODS:

The meta‐analysis primary outcomes were overall survival (OS), local control (LC), and distant brain control (DBC). Secondary outcomes were neurocognition, quality of life (QOL), and toxicity. Using published Kaplan‐Meier curves, results were pooled using hazard ratios (HR).

RESULTS:

Two RCTs reported on WBRT and SRS boost versus WBRT alone. For multiple brain metastases (2‐4 tumors) we conclude no difference in OS, and LC significantly favored WBRT plus SRS boost. Three RCTs reported on SRS alone versus WBRT plus SRS boost (1‐4 tumors). There was no difference in OS despite both LC and DBC significantly favoring WBRT plus SRS boost. Although secondary endpoints could not be pooled for meta‐analysis, those RCTs evaluating SRS alone conclude better neurocognition using the validated Hopkins Verbal Learning Test, no adverse risk in deteriorating Mini‐Mental Status Exam scores or in maintaining performance status, and fewer late toxicities. We conclude insufficient data for QOL outcomes.

CONCLUSIONS:

For selected patients, we conclude no OS benefit for WBRT plus SRS boost compared with SRS alone. Although additional WBRT improves DBC and LC, SRS alone should be considered a routine treatment option due to favorable neurocognitive outcomes, less risk of late side effects, and does not adversely affect the patients performance status. Cancer 2012. © 2011 American Cancer Society.     

Application of recursive partitioning analysis and evaluation of the use of whole brain radiation among patients treated with stereotactic radiosurgery for newly diagnosed brain metastases

PURPOSE: To evaluate the usefulness of whole brain radiotherapy (WBRT) and of the Radiation Therapy Oncology Group recursive partitioning analysis (RPA) for brain metastases among patients receiving stereotactic radiosurgery (SRS). METHODS AND MATERIALS: A retrospective analysis was performed on 135 patients who underwent linear accelerator (Linac) (n = 73) or Gamma Knife (n = 62) SRS for newly diagnosed brain metastases at the Cleveland Clinic Foundation between 8/89 and 12/98. Univariate and multivariate analyses were performed to evaluate the effects of age, primary site, control of the primary, interval to development of brain metastases (disease-free interval [DFI]), number of brain metastases, presence of extracranial metastases, Karnofsky performance status (KPS), treatment of brain metastases, and RPA class on overall survival. RESULTS: Application of the RPA classification revealed 29 patients fit the criteria for class I, 96 for class II, and 10 for class III. All of the patients underwent SRS. Fifty-seven patients also received WBRT at the time of initial presentation (SRS and immediate WBRT), and 78 patients received WBRT only if CNS relapse occurred (SRS alone). The median survival for all patients was 7.9 months (range: 1.1-90.1), and was 11.2 months for RPA class I compared to 6. 9 months for RPA classes II-III (p = 0.016). Median survival was 10. 5 months following SRS alone compared to 6.4 months following SRS and WBRT (p = 0.07). On univariate analysis, KPS >/= 80% (p = 0.002) and absence of systemic disease (p = 0.013) were also associated with longer survival, whereas control of the primary, DFI, and number of brain metastases did not have an impact. Multivariate analysis revealed only RPA class (p = 0.023) to be an independent predictor for overall survival, whereas treatment group (p = 0.079) was only marginally significant. At 2 years, immediate WBRT improved control at the original site of metastases (80% vs. 52%, p = 0.03) and prevention of new metastatic sites within the brain, 74% vs. 48% (p = 0.06). The 2-year intracranial disease-free survival was 60% following SRS and WBRT compared to only 34% following SRS alone (p = 0.03). CONCLUSIONS: Despite the inherent biases to select more favorable patients for SRS, the RPA class retains its prognostic value. Omission of WBRT from the initial management was not detrimental in terms of overall survival; however, progressive disease occurred in over 50% of patients treated in this manner. Further studies are required to determine which, if any, patients should be considered for SRS with WBRT held in reserve.     

伽玛刀治疗肺癌脑转移瘤生存与预后分析

目的:分析伽玛刀治疗肺癌脑转移瘤患者的生存及预后影响因素。方法:回顾性分析行伽玛刀治疗的56例肺癌脑转移瘤患者,单纯SRS组22例,单纯SRT组16例,联合全脑放疗(WBRT)组9例,行伽玛刀挽救组7例,行联合WBRT挽救组2例。Log rank法单因素分析影响预后的因素。结果:全组经治疗后6月、1年生存率分别为50%、10%,中位生存期为6个月。单纯SRS、单纯SRT、SRS联合WBRT、SRS/SRT挽救组、SRS+WBRT挽救组6月生存率分别为59%、55%、40%、33%、0%,中位生存期分别为8、9、6、5、3个月（P=0.005）。其中,SRS对SRT（P=0.157）、SRS对SRS+WBRT（P=0.551）、SRT对SRS+WBRT（P=0.266）、SRS/SRT挽救组对SRS+WBRT挽救组（P=0.177）无统计学意义。单因素分析显示影响总生存率的因素有原发灶的控制情况、病理、中枢外转移情况、KPS评分、RPA分级、病灶所处位置、前期化疗、前期颅内治疗、病灶数目(P=0.000、0.013、0.002、0.000、0.000、0.000、0.043、0.011、0.037)。多因素分析显示KPS评分、原发灶控制、病理、前期颅内处理影响生存（P=0.000、0.005、0.006、0.002）。结论:用伽玛刀行单次SRS或分次SRT或与WBRT联合治疗在对生存获益上相似;KPS评分、原发灶控制情况、病理类型、前期颅内处理是影响生存的主要因素。     

脑转移瘤放射治疗的预后因素分析及预后模型的建立

背景与目的：放射治疗是大多数脑转移瘤最主要的治疗手段,而预后却受多种因素的影响。本研究探讨影响肿瘤脑转移患者放射治疗生存期的预后因素并建立预后指数模型。方法：选择2008年1月—2011年7月符合入组条件接受放射治疗的脑转移患者140例,对各影响因素行单因素分析,差异有统计学意义的因素再行多因素分析,筛选出与预后最为相关的因素,并计算预后指数(prognostic index,PI)。同时,评估递归分区分析(recursive partitioning analysis classes,RPA)、脑转移基本评分(basic score for brain metastases,BS-BM)及等级预后评估标准(the graded prognostic assessment index,GPA)是否与预后相关。结果：全组中位生存时间为222 d。单因素检验提示卡氏评分(karnofsky performance score,KPS)、脑转移数目、中枢外转移、原发灶控制、放疗剂量、血红蛋白与预后相关;多因素分析筛选出KPS(P=0.002、Wald=9.700)、中枢外转移(P=0.018,Wald=5.604)、原发灶控制(P=0.001、Wald=10.212)3个因素影响总生存期。Log-rank检验提示,3种评分模式均与预后相关,而对于本组患者的3、6个月生存概率的预测,PI优于其他评分模式。结论：PI预后指数模型和3种预后指数均能反映预后,但PI更佳。     

吉非替尼同步γ射线立体定向外科加全脑放疗治疗非小细胞肺癌脑转移瘤的临床研究

评价吉非替尼同步伽马射线立体定向外科加全脑放疗治疗非小细胞肺癌（NSCLC）脑转移瘤的作用和获益影响因素。方法:回顾性分析23例NSCLC脑转移瘤患者接受吉非替尼同步γ射线立体定向外科治疗加全脑放疗后的疗效、疾病进展时间、总生存时间、预后影响因素及不良反应。结果:颅内病灶的疗效为:CR 2例,PR 16例,SD 3例,PD 2例,有效率78.3%（18/23）,疾病控制率91.3%（21/23）。全身病变的总体疗效为:CR 0例,PR 5例,SD 12例,PD 6例,有效率21.7%（5/23）,疾病控制率73.9%（17/23）。中位疾病进展时间为8.3个月,中位生存时间为12.8个月。单因素分析显示:KPS评分、肿瘤累及体积、病理类型、RPA分级为疾病进展时间预测因素（P均<0.05）;而KPS评分、肿瘤累及体积、RPA分级则是生存时间预测因素（P均<0.05）。吉非替尼不良反应主要为Ⅰ~Ⅱ度皮疹和腹泻,患者均可耐受。结论:吉非替尼同步γ射线立体定向外科治疗加全脑放疗后的治疗NSCLC脑转移瘤,有效率和疾病控制率高,具有较长的中位疾病进展时间和生存时间,不良反应轻微,是一种很有价值的治疗方法。其中,KPS评分、肿瘤体积、病理类型（腺癌）、RPA分级是影响获益和生存的重要因素。      

Dose escalation beyond 30 grays in 10 fractions for patients with multiple brain metastases

BACKGROUND: Whole-brain radiotherapy (WBRT) to 30 grays (Gy) in 10 fractions is the standard treatment in patients with multiple brain metastases in the majority of treatment centers worldwide. The current study investigated the potential benefit of dose escalation beyond 30 Gy. METHODS: Data regarding 416 patients who were treated with WBRT for multiple brain metastases were evaluated retrospectively. Survival and freedom from recurrent brain metastasis (local control) of 257 patients who were treated with 10 fractions of 3 Gy each for 2 weeks were compared with those of 159 patients treated with 45 Gy in 15 fractions for 3 weeks or 40 Gy in 20 fractions for 4 weeks. Eight additional potential prognostic factors were investigated including age, gender, Karnofsky performance score (KPS), tumor type, interval between tumor diagnosis and RT, number of metastases, extracranial metastases, and Recursive Partitioning Analysis (RPA) class. RESULTS: On multivariate analysis, improved survival was found to be associated with lower RPA class (P < .001), age <60 years (P = .026), KPS >or=70 (P < .001), and absence of extracranial metastases (P = .003). A trend was observed for number of metastases (2-3 vs >or=4; P = .07). Improved local control was associated with a KPS >or=70 (P < .001) and breast cancer (P < .001). A trend was observed for number of metastases (P = .059). The RT schedule did not appear to have any significant impact on survival (P = .86) or local control (P = .61). The subgroup analyses, performed for each of the 3 RPA classes, did not demonstrate a significantly better outcome with dose escalation. CONCLUSIONS: Dose escalation beyond 30 Gy in 10 fractions does not appear to improve survival or local control in patients with multiple brain metastases but does increase the treatment time and cost of therapy.     

Surgical resection followed by whole brain radiotherapy versus whole brain radiotherapy alone for single brain metastasis

PURPOSE: To compare the outcome of surgical resection followed by whole brain radiotherapy (WBRT) with WBRT alone in patients treated for single brain metastasis. METHODS AND MATERIALS: The data from 195 patients with single brain metastases were retrospectively evaluated. Of the 195 patients, 99 underwent resection of the metastasis followed by WBRT and 96 underwent WBRT alone. Seven additional potential prognostic factors were investigated: age, gender, Eastern Cooperative Oncology Group performance score, tumor type, interval between initial tumor diagnosis and WBRT, extracranial metastases, and recursive partitioning analysis class. Both treatment groups were well balanced for these factors. RESULTS: On multivariate analysis, improved survival was associated with resection (relative risk [RR], 1.20; 95% confidence interval [CI], 1.11-1.31; p < 0.001), lower recursive partitioning analysis class (RR, 1.58; 95% CI, 1.22-2.06; p < 0.001), age < or = 61 years (RR, 1.79; 95% CI, 1.23-2.61; p = 0.002), Eastern Cooperative Oncology Group performance score of 0-1 (RR, 2.47; 95% CI, 1.70-3.59; p < 0.001), and the absence of extracranial metastases (RR, 1.99; 95% CI, 1.41-2.79; p < 0.001). Improved local control was associated with resection (RR, 1.25; 95% CI, 1.11-1.41; p < 0.001) and age < or = 61 years (RR, 1.77; 95% CI, 1.09-2.88; p = 0.020). Improved brain control distant from the original site was associated with lower recursive partitioning analysis class (RR, 1.65; 95% CI, 1.03-2.69; p < 0.035), age < or = 61 years (RR, 1.81; 95% CI, 1.12-2.96; p = 0.016), and the absence of extracranial metastases (RR, 2.42; 95% CI, 1.52-3.88; p < 0.001). Improved control within the entire brain was associated with surgery (RR, 1.24; 95% CI, 1.12-1.38; p < 0.001) and age < or = 61 years (RR, 1.83; 95% CI, 1.21-2.77; p = 0.004). CONCLUSION: In patients with a single brain metastasis, the addition of resection to WBRT improved survival, local control at the original metastatic site, and control within the entire brain, but did not prevent the development of new brain metastases distant to the original site.     

Validation of the Disease-Specific GPA for Patients With 1 to 3 Synchronous Brain Metastases in Newly Diagnosed NSCLC

Background

The disease-specific graded prognostic assessment (DS-GPA) for brain metastases is a powerful prognostic tool but has not been validated for patients with synchronous brain metastases (SBM) in newly diagnosed non–small-cell lung cancer (NSCLC).

Intracranial control and radiographic changes with adjuvant radiation therapy for resected brain metastases: whole brain radiotherapy versus stereotactic radiosurgery alone

The aim of this study was to compare outcomes of postoperative whole brain radiation therapy (WBRT) to stereotactic radiosurgery (SRS) alone in patients with resected brain metastases (BM). We reviewed records of patients who underwent surgical resection of BM followed by WBRT or SRS alone between 2003 and 2013. Local control (LC) of the treated resected cavity, distant brain control (DBC), leptomeningeal disease (LMD), overall survival (OS), and radiographic leukoencephalopathy rates were estimated by the Kaplan–Meier method. One-hundred thirty-two patients underwent surgical resection for 141 intracranial metastases: 36 (27 %) patients received adjuvant WBRT and 96 (73 %) received SRS alone to the resection cavity. One-year OS (56 vs. 55 %, p = 0.64) and LC (83 vs. 74 %, p = 0.31) were similar between patients receiving WBRT and SRS. After controlling for number of BM, WBRT was associated with higher 1-year DBC compared with SRS (70 vs. 48 %, p = 0.03); single metastasis and WBRT were the only significant predictors for reduced distant brain recurrence in multi-variate analysis. Freedom from LMD was higher with WBRT at 18 months (87 vs. 69 %, p = 0.045), while incidence of radiographic leukoencephalopathy was higher with WBRT at 12 months (47 vs. 7 %, p = 0.001). One-year freedom from WBRT in the SRS alone group was 86 %. Compared with WBRT for patients with resected BM, SRS alone demonstrated similar LC, higher rates of LMD and inferior DBC, after controlling for the number of BM. However, OS was similar between groups. The results of ongoing clinical trials are needed to confirm these findings.     

乳腺癌脑转移全脑放疗预后及预后指数分析

目的 探讨乳腺癌脑转移患者全脑放疗(WBRT)预后以及不同预后指数差别。
方法 对2006-2010年间接受WBRT的99例乳腺癌脑转移患者进行Logrank法单因素与Cox法多因素预后分析,计算并比较RPA、GPA、BSBM、Rades、Carsten预后指数评分的敏感性和特异性。
结果 全组患者中位随访时间49个月,中位生存期为10个月。单因素分析显示年龄、脑转移时卡氏评分、是否伴有颅外转移、原发肿瘤控制情况、脑转移数目和WBRT后全身治疗与总生存相关(χ²=0.00~55.51,P=0.013~0.000),多因素分析证实卡氏评分<70和WBRT后全身治疗与总生存相关(χ²=35.26、7.21,P=0.000、0.007)。RPA、GPA、BSBM、Rades、Carsten预后指数评分对预测生存期≤3个月乳腺癌脑转移患者的敏感性和特异性分别为100%和85%、95%和62%、95%和86%、95%和84%、95%和85%。
结论 乳腺癌脑转移患者WBRT后全身治疗可改善患者总生存。对预测生存期≤3个月患者敏感性最好的为RPA指数,特异性最好的为BSBM指数。     

Salvage stereotactic radiosurgery effectively treats recurrences from whole-brain radiation therapy

BACKGROUND.

The purpose of the current study was to examine overall survival (OS) and time to local failure (LF) in patients who received salvage stereotactic radiosurgery (SRS) for recurrent brain metastases (BM) after initial management that included whole‐brain radiation therapy (WBRT).

METHODS.

The records of 1789 BM patients from August 1989 to November 2004 were reviewed. Of these, 111 underwent WBRT as part of their initial management and SRS as salvage. Patients were stratified by Radiation Therapy Oncology Group (RTOG) recursive partitioning analysis class, primary disease, dimension of the largest metastases and number of BM at initial diagnosis, and time to first brain recurrence after WBRT. Overall survival, survival after SRS, and time to local and distant failure were analyzed.

RESULTS.

The median OS from the initial diagnosis of BM was 17.7 months. Median survival after salvage SRS for the entire cohort was 9.9 months. Median survival after salvage SRS was 12.3 months in patients who had their first recurrence >6 months after WBRT versus 6.8 months for those who developed disease recurrence ≤6 months after (P = .0061). Primary tumor site did not appear to affect survival after SRS. Twenty‐eight patients (25%) developed local recurrence after their first SRS with a median time of 5.2 months. A dose <22 grays and lesion size >2 cm were found to be predictive of local failure.

CONCLUSIONS.

In this study, patients who recurred after WBRT and were treated with salvage SRS were found to have good local control and survival after SRS. WBRT provided good initial control, as 45% of these patients failed >6 months after WBRT. Those with a longer time to failure after WBRT had significantly longer survival after SRS. Cancer 2008. © 2008 American Cancer Society.     

非小细胞肺癌脑转移的研究进展

非小细胞肺癌脑转移的治疗对肿瘤学家是一种挑战。虽然近年脑转移研究有所进展,但生存率并不乐观。本文阐述非小细胞肺癌脑转移的临床特点、诊断方法、预后因素以及治疗进展。脑转移最常见的症状为因颅内压力增高所致的头痛。评价脑转移时,头颅MRI较CT优越。最常用的预后标准是肿瘤放射治疗组(RTOG)的RPA分级。关于全脑放疗、立体定向放射外科、手术以及化疗治疗脑转移的作用仍存在争议。全脑放疗常作为脑转移的标准治疗方案。SRS对单一或多个脑转移灶的治疗可代替外科切除。许多数据证明化疗有较好的颅内作用,这引起全身化疗治疗脑转移的研究热点。确立预后因素和其他临床特点后,才能制定最适合个体患者的治疗。     

Multidisciplinary treatment of brain metastases derived from clear cell renal cancer incorporating stereotactic radiosurgery

BACKGROUND

Brain metastases are a frequent complication in patients with metastatic clear cell renal cancer. Survival after whole‐brain radiotherapy (WBRT) is disappointing. A retrospective analysis of multimodality treatment was performed in patients who had received linear accelerator (LINAC)‐based stereotactic radiosurgery (SRS).

METHODS

Thirty‐two patients underwent SRS‐based treatment for 71 metastatic foci between 2000 and 2006. All patients had a Karnofsky performance status ≥70 and all 32 patients had extracranial metastatic disease (Radiation Therapy Oncology Group recursive partitioning analysis [RPA] Class 2). Survival was calculated from the time of diagnosis of brain metastases. The minimum potential follow‐up was 1 year after SRS. Univariate and multivariate analysis of potential prognostic factors affecting survival was performed.

RESULTS

Twenty‐six patients required only 1 SRS treatment (84%) to achieve central nervous system (CNS) control, whereas 5 patients received 2 to 3 treatments (16%). The median survival of renal cancer patients from the diagnosis of brain metastases was 10.1 months (95% confidence interval, 6.4‐14.8 months). One‐year and 3‐year survival rates were 43% and 16%, respectively. The addition of surgery or WBRT did not appear to prolong survival. Immunotherapy after control of brain metastases with SRS appeared to result in significantly improved survival. Survival was also found to be strongly influenced by prognostic stratification of metastatic disease using Motzer or modified risk criteria.

CONCLUSIONS

The results of the current study demonstrated that SRS‐based treatment of patients with up to 5 brain metastases from clear cell renal cancer is feasible and results in excellent CNS control. Survival beyond 3 years from the time of diagnosis of brain metastases was achievable in 16% of patients and was associated with the use of systemic immunotherapy with interleukin‐2 and interferon but not antiangiogenic agents. Cancer 2008. © 2008 American Cancer Society.     

Prognostic Factors in Patients with Non-small Cell Lung Carcinoma and Brain Metastases: a Malaysian Perspective

Background: Brain metastases occur in about 20-40% of patients with non-small-cell lung carcinoma(NSCLC), and are usually associated with a poor outcome. Whole brain radiotherapy (WBRT) is widely used butincreasingly, more aggressive local treatments such as surgery or stereotactic radiosurgery (SRS) or stereotacticradiotherapy (SRT) are being employed. In our study we aimed to describe the various factors affecting outcomesin NSCLC patients receiving local therapy for brain metastases. Materials and Methods: The case records of 125patients with NSCLC and brain metastases consecutively treated with radiotherapy at two tertiary centres fromJanuary 2006 to June 2012 were analysed for patient, tumour and treatment-related prognostic factors. Patientsreceiving SRS/SRT were treated using Cyberknife. Variables were examined in univariate and multivariatetesting. Results: Overall median survival was 3.4 months (95%CI: 1.7-5.1). Median survival for patients withmultiple metastases receiving WBRT was 1.5 months, 1-3 metastases receiving WBRT was 3.6 months and 1-3metastases receiving surgery or SRS/SRT was 8.9 months. ECOG score (≤2 vs >2, p=0.001), presence of seizure(yes versus no, p=0.031), treatment modality according to number of brain metastases (1-3 metastases+surgeryor SRS/SRT±WBRT vs 1-3 metastases+WBRT only vs multiple metastases+WBRT only, p=0.007) and the use ofpost-therapy systemic treatment (yes versus no, p=0.001) emerged as significant on univariate analysis. All fourfactors remained statistically significant on multivariate analysis. Conclusions: ECOG ≤2, presence of seizures,oligometastatic disease treated with aggressive local therapy (surgery or SRS/SRT) and the use of post-therapysystemic treatment are favourable prognostic factors in NSCLC patients with brain metastases.