脑转移瘤立体定向放射外科治疗

立体定向脑放疗放射外科(SRS)可治疗单发或多发脑转移瘤，与全脑放射治疗(WBRT)相比，能延长生存时间、提高生活质量。用于全身肿瘤控制或稳定、直径≤3．5cm单发脑转移瘤患者，具有与手术配合WBRT相似的疗效。SRS加WBRT与单纯SRS治疗相比，能提高颅内无进展生存期，但未能延长生存时间。脑转移瘤复发后SRS治疗能取得较好疗效。     

脑转移瘤的临床治疗进展

脑转移瘤的预后较差，但通过肿瘤外科，内科，放疗科的共同参与，选择合适的治疗方案，脑转移瘤的治疗效果将得到进一步改善。     

脑转移瘤放疗前后CT影象分析

脑转移瘤是脑内发病率较高的肿瘤之一,占脑肿瘤的3～10％。其中大部分来源于肺癌,其次为乳腺癌、肾癌等。脑转移瘤的治疗方案各家意见不一,多发肿瘤主张化疗的居多,单发肿瘤主张手术切陈的居多。近年来随着放射治疗的进展,对脑转移瘤的放射治疗进行了大量的研究,报导很多。但对脑转移瘤放射治疗前与治疗后的影象学改变的研究则鲜见报导。本文对我院15例肺癌脑转移瘤放疗前后的CT影象学改变做一分析报导,以期提高对脑转移瘤的放射治疗疗效的认识水平。     

立体定向放射外科治疗脑转移瘤

本文对脑转移瘤立体定向放射手射外科的文献进行总结，讨论了立体定向放射外科治疗脑转移瘤的适应证，治疗方法，治疗效果和并发症。     

脑转移瘤立体定向放射外科治疗

立体定向脑放疗放射外科(SRS)可治疗单发或多发脑转移瘤,与全脑放射治疗(WBRT)相比,能延长生存时间、提高生活质量.用于全身肿瘤控制或稳定、直径≤3.5cm单发脑转移瘤患者,具有与手术配合WBRT相似的疗效.SRS加WBRT与单纯SRS治疗相比,能提高颅内无进展生存期,但未能延长生存时间.脑转移瘤复发后SRS治疗能取得较好疗效.     

放疗联合替莫唑胺治疗肺癌脑转移瘤的疗效观察

目的探讨放疗联合替莫唑胺治疗肺癌脑转移瘤的临床疗效和不良反应。方法选取2012年5月至2016年6月间山东省济南市中西医结合医院收治的63例肺癌脑转移患者,采用随机数表法分为治疗组(32例)和对照组(31例)。治疗组患者采用放疗加口服替莫唑胺治疗,对照组患者采用单纯放疗治疗,比较两组患者的临床疗效和不良反应。结果两组患者脑部主要症状改善率比较,放疗剂量30Gy时,治疗组患者有效率为84. 4%(27例),对照组为61. 3%(19例),差异有统计学意义(P <0. 05)。治疗结束时,治疗组患者主要脑部症状总改善率为96. 9%(31例),对照组为77. 4%(24例),差异有统计学意义(P <0. 05)。两组患者治疗后脑转移灶直径变化情况中各项治疗效果比较,差异均无统计学意义(均P> 0. 05)。治疗后,治疗组患者生活质量评分提高率为90. 6%(29例),对照组为64. 5%(20例),差异有统计学意义(P <0. 05)。治疗组患者主要不良反应为血液毒性反应,Ⅱ～Ⅲ级骨髓抑制率为43. 8%(14例);消化道反应率为40. 6%(13例),主要为恶心、呕吐等,但均为Ⅰ～Ⅱ级。治疗后1年,治疗组患者生存率为62. 5%(20例),对照组为35. 5%(11例),差异有统计学意义(P <0. 05)。治疗组患者1年生存率与脑转移灶多少和有无颅外转移等有一定关系,单发脑转移患者的1、2年生存率明显高于多发患者,差异有统计学意义(P <0. 05)。结论放疗联合替莫唑胺治疗肺癌脑转移瘤患者症状改善快且明显,有较好的近期疗效,不良反应可耐受。     

手术放射手术和放疗治疗脑转移瘤疗效的比较

回顾性分析手术、立体定向放射手术和放疗治疗脑转移瘤的疗效。1991年1月至1995年12月,59例脑转移瘤分别采用手术(10例),放射手术(19例)和放疗(30例)治疗。手术组术后全脑照射40Gy,放射手术剂量20～30Gy(平均21.1Gy),放疗组全脑照射30～40Gy,然后缩野追加10～24Gy。手术组、放射手术组、放疗组的中位生存期分别为12.5个月、11.2个月、5.6个月;一年生存率分别为60％、47.4％、20％。手术和放射手术治疗脑转移的疗效相似(P=0.25),且明显好于常规放疗(P<0.05)。     

Patterns of distant brain recurrences after radiosurgery alone for newly diagnosed brain metastases: Implications for salvage therapy

Introduction

Single modality radiosurgery (RS) is an established treatment option for patients with brain metastases (BM) with the aim of achieving optimal local control while avoiding toxicity from whole brain radiotherapy (WBRT). Published studies generally lack detailed data on distant brain recurrence (DBR) rates and characteristics. This study describes the patterns of DBR and consequences for salvage treatment in a group of patients treated with RS alone for 1–3 BM.

Materials and methods

Between 2002 and 2012, 443 patients were treated with RS alone in doses ranging 15–24 Gy in 1–3 fractions. Patient selection for RS was performed using triple dose gadolinium-enhanced MRI scans, obtained with slice distance of 2 mm (until 2008), 1.5 mm (2008–2012), and of 1 mm (from 2012). During follow-up, a DBR was observed in 147 patients, but in 20 of these patients (14%) these “new lesions” could retrospectively be seen on the planning MRI scan. These missed metastases had a median size of 2 mm, and in order to study real DBR patterns, these patients were excluded from analysis.

Results

Actuarial DBR rates at 6, 12 and 24 months in the remaining 423 patients were 21%, 41% and 54%, respectively, with a median time to DBR of 5.6 months. In 42% of DBR, a single new lesion was seen, in 70% there were ?3 new lesions. Median diameter of the DBR was 6 mm; 97% of lesions were ?30 mm. Salvage therapy was delivered in 82% of DBR patients, consisting of WBRT (46%), repeated RS (27%), or systemic treatment (9%). A RPA classification system (DBR-RPA), based on WHO performance status and interval between initial RS and diagnosis of DBR, was developed to estimate life expectancy after the development of DBR, which can be used to guide salvage therapy.

Conclusions

In this study of patients treated with RS alone, only 25% of treated patients needed salvage treatment for DBR, and ultimately only 18% of all patients underwent WBRT at any time during follow-up. A three-monthly MRI follow-up scheme identifies DBR at an early stage with respect to size and number of lesions, and most patients were asymptomatic at radiological diagnosis.     

Stereotactic radiosurgery for four or more intracranial metastases

PURPOSE: To evaluate the outcomes after a single stereotactic radiosurgery procedure for the care of patients with 4 or more intracranial metastases. METHODS AND MATERIALS: Two hundred five patients with primary malignancies, including non-small-cell lung carcinoma (42%), breast carcinoma (23%), melanoma (17%), renal cell carcinoma (6%), colon cancer (3%), and others (10%) underwent gamma knife radiosurgery for 4 or more intracranial metastases at one time. The median number of brain metastases was 5 (range, 4-18) with a median total treatment volume of 6.8 cc (range, 0.6-51.0 cc). Radiosurgery was used as sole management (17% of patients), or in combination with whole brain radiotherapy (46%) or after failure of whole brain radiotherapy (38%). The median marginal radiosurgery dose was 16 Gy (range, 12-20 Gy). The mean follow-up was 8 months. RESULTS: The median overall survival after radiosurgery for all patients was 8 months. The 1-year local control rate was 71%, and the median time to progressive/new brain metastases was 9 months. Using the Radiation Therapy Oncology Group recursive partitioning analysis (RPA) classification system, the median overall survivals for RPA classes I, II, and III were 18, 9, and 3 months, respectively (p < 0.00001). Multivariate analysis revealed total treatment volume, age, RPA classification, and marginal dose as significant prognostic factors. The number of metastases was not statistically significant (p = 0.333). CONCLUSION: Radiosurgery seems to provide survival benefit for patients with 4 or more intracranial metastases. Because total treatment volume was the most significant predictor of survival, the total volume of brain metastases, rather than the number of metastases, should be considered in identifying appropriate radiosurgery candidates.     

Microsurgery plus whole brain irradiation versus Gamma Knife surgery alone for treatment of single metastases to the brain: a randomized controlled multicentre phase III trial

Journal of Neuro-Oncology - Background Is Gamma Knife surgery alone as effective as surgery plus whole brain irradiation (WBRT) for patients with a single, small-sized brain metastasis? Methods...     

脑转移瘤的放射治疗

脑转移是晚期肿瘤治疗失败的常见原因,放疗是其主要治疗手段之一.随着放疗技术的不断发展,脑转移瘤患者的生存期及生活质量明显改善.全脑放疗、立体定向放疗以及两者联合是目前主要治疗方法,但在最佳剂量分割、最佳联合时期及患者的选择等方面尚待进一步明确.新的放疗技术如同期加量放疗已成为目前的研究热点.     

Radiosurgery for brain metastases: a score index for predicting prognosis

Purpose: To analyze a prognostic score index for patients with brain metastases submitted to stereotactic radiosurgery (the Score Index for Radiosurgery in Brain Metastases [SIR]).

Methods and Materials: Actuarial survival of 65 brain metastases patients treated with radiosurgery between July 1993 and December 1997 was retrospectively analyzed. Prognostic factors included age, Karnofsky performance status (KPS), extracranial disease status, number of brain lesions, largest brain lesion volume, lesions site, and receiving or not whole brain irradiation. The SIR was obtained through summation of the previously noted first five prognostic factors. Kaplan-Meier actuarial survival curves for all prognostic factors, SIR, and recursive partitioning analysis (RPA) (RTOG prognostic score) were calculated. Survival curves of subsets were compared by log-rank test. Application of the Cox model was utilized to identify any correlation between prognostic factors, prognostic scores, and survival.

Results: Median overall survival from radiosurgery was 6.8 months. Utilizing univariate analysis, extracranial disease status, KPS, number of brain lesions, largest brain lesion volume, RPA, and SIR were significantly correlated with prognosis. Median survival for the RPA classes 1, 2, and 3 was 20.19 months, 7.75 months, and 3.38 months respectively (p = 0.0131). Median survival for patients, grouped under SIR from 1 to 3, 4 to 7, and 8 to 10, was 2.91 months, 7.00 months, and 31.38 months respectively (p = 0.0001). Using the Cox model, extracranial disease status and KPS demonstrated significant correlation with prognosis (p = 0.0001 and 0.0004 respectively). Multivariate analysis also demonstrated significance for SIR and RPA when tested individually (p = 0.0001 and 0.0040 respectively). Applying the Cox Model to both SIR and RPA, only SIR reached independent significance (p = 0.0004).

Conclusions: Systemic disease status, KPS, SIR, and RPA are reliable prognostic factors for patients with brain metastases submitted to radiosurgery. Applying SIR and RPA classifications to our patients’ data, SIR demonstrated better accuracy in predicting prognosis. SIR should be further tested with larger patient accrual and for all patients with brain metastases subjected or not to stereotactic radiosurgery.     

多发性脑转移瘤立体定向放疗的探讨

背景与目的:立体定向放疗(stereotactic radiotherapy,SRT)技术在颅内肿瘤治疗中具有明显优势,但在颅内多发肿瘤治疗中应用的报告较少。本文回顾性分析多发性脑转移瘤患者的治疗结果,评价SRT的治疗作用和应用特点。方法:1996年6月至2002年12月间,136例多发性脑转移瘤患者接受放射治疗。38.2%(52/136)接受单纯常规照射(称常规组),61.8%(84/136)接受SRT(包括单独SRT和全脑照射结合SRT,统称SRT组)。结果:临床有效率分别为常规组86.5%和SRT组96.4%(P=0.02);颅内转移瘤(直径>2cm)消除率分别为常规组36.0%和SRT组70.4%(P=0.007);顽固性脑水肿发生率分别为常规组9.6%和SRT组8.3%(P=0.767);颅内复发率分别为常规组19.4%和SRT组25.0%(P=0.653)。常规组和SRT组的中位生存期和1年生存率分别为6.5个月、10.5个月(P=0.014)和21.2%、40.5%(P=0.023)。结论:合理应用SRT技术可以提高多发性脑转移瘤患者的生存质量和肿瘤疗效、减少颅内复发和放射损伤,从而延长患者生存期。     

Long-term survival after brain metastases from tracheal carcinoma

A case of prolonged survival after radiotherapy for primary tracheal squamous cell carcinoma and the subsequent brain metastases is reported. The patient is alive and well without any sign of relapse, approximately six years after the onset of brain metastases from tracheal carcinoma. Radiotherapy proved useful in the treatment of both the primary tracheal carcinoma and the brain metastases.     

２３例脑转移瘤射波刀治疗的临床分析

目的　观察射波刀治疗脑部转移瘤的近期临床疗效。方法　收集２００９年３月至２００９年１０月我院射波刀治疗的脑转移瘤患者２３例,其中原发灶为肺癌１３例、消化道肿瘤５例、恶性淋巴瘤２例、肾上腺癌１例、宫颈癌１例、鼻咽癌１例。脑转移灶共计３５个,直径范围０.５～６.８ｃｍ,平均为１.８ｃｍ。射波刀通过数百个方向的射线束照射,使得８０％等剂量面包括９５％以上计划靶体积。采用低分割照射５～２０Ｇｙ／次,１～５次,中位值３次,总剂量２０～３４Ｇｙ,中位值２５Ｇｙ,生物等效剂量５０～８０.６Ｇｙ。结果　治疗后１周临床症状改善率９５.６％;治疗后３个月的治疗有效率（ＣＲ＋ＰＲ）为７４.３％,局部控制率（ＣＲ＋ＰＲ＋ＳＤ）为８８.６％。结论　射波刀是治疗脑转移瘤的有效方法。     

Radiotherapy for cerebral metastases in children

Twelve children with cerebral metastases from non-lymphomatous primary tumors are reviewed. Eleven were treated with radiotherapy and four are alive without clinical or radiographic evidence of intracranial tumor $\text{2–7}{}^{\mathrm{<mtext>1</mtext><mtext>2</mtext>}}$ years later. Three of the four survivors are free of neurologic impairments. Eight patients died within two months of detection of cerebral metastases. There were no obvious differences between those patients who survived and those who did not, concerning the primary tumor, age at diagnosis, duration of symptoms or the interval from the primary to the cerebral metastases. All survivors are male.