Stereotactic radiosurgery of the postoperative resection cavity for brain metastases

PURPOSE: The purpose of this study was to analyze results of adjuvant stereotactic radiosurgery (SRS) targeted at resection cavities of brain metastases without whole-brain irradiation (WBI). METHODS AND MATERIALS: Patients who underwent SRS to the tumor bed, deferring WBI after resection of a brain metastasis, were retrospectively identified. RESULTS: Seventy-two patients with 76 cavities treated from 1998 to 2006 met inclusion criteria. The SRS was delivered to a median marginal dose of 18.6 Gy (range, 15-30 Gy) targeting an average tumor volume of 9.8 cm(3) (range, 0.1-66.8 cm(3)). With a median follow-up of 8.1 months (range, 0.1-80.5 months), 65 patients had follow-up imaging assessable for control analyses. Actuarial local control rates at 6 and 12 months were 88% and 79%, respectively. On univariate analysis, increasing values of conformality indices were the only treatment variables that correlated significantly with improved local control; local control was 100% for the least conformal quartile compared with 63% for the remaining quartiles. Target volume, dose, and number of sessions were not statistically significant. CONCLUSIONS: In this retrospective series, SRS administered to the resection cavity of brain metastases resulted in a 79% local control rate at 12 months. This value compares favorably with historic results with observation alone (54%) and postoperative WBI (80-90%). Given the improved local control seen with less conformal plans, we recommend inclusion of a 2-mm margin around the resection cavity when using this technique.     

SIMULTANEOUS THORACO－CRANIAL OPERATION FOR THE TREATMENT OF LUNG CANCER WITH BRAIN METASTASES

ＳＩＭＵＬＴＡＮＥＯＵＳＴＨＯＲＡＣＯ－ＣＲＡＮＩＡＬＯＰＥＲＡＴＩＯＮＦＯＲＴＨＥＴＲＥＡＴＭＥＮＴＯＦＬＵＮＧＣＡＮＣＥＲＷＩＴＨＢＲＡＩＮＭＥＴＡＳＴＡＳＥＳＣｈｅｎＪｉａｎ陈建；ＬｉｕＤａｏｋｕｎ刘道坤；ＬｉｕＪｕｎｈｕａ刘俊华；ＳｈｉＺｈｏ...     

The influence of surgery and radiation therapy on patients with brain metastases

The place for operation and for radiation therapy in the management of brain metastases is reviewed from the experience of 1895 patients treated in two studies of the Radiation Therapy Oncology Group. Operative removal may be of benefit to patients with solitary peripheral lesions in non-critical brain locations. Operation is also appropriate when the diagnosis is in doubt. Radiation therapy with appropriate steroid management is of benefit to patients with multiple metastases or where operative intervention is not reasonable. Short course low-dose treatment has been as beneficial as more aggressive prolonged radiation therapy.     

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...     

Current concepts and controversies in the treatment of parenchymal brain metastases: improved outcomes with aggressive management

The multimodality management of brain metastases has undergone significant refinement in the last decade. Although brain metastases remain a significant source of morbidity and mortality for many cancer patients, aggresive management has led to pronounced gains in neurological functioning, disease free survival and overall survival compared to standard treatment regimens consisting of only whole brain radiation therapy. Representative studies reviewing the role of aggressive management approaches including surgical resection with or without whole brain radiation therapy or non-surgical approaches employing stereotactic radiosurgery alone or in combination with whole brain radiation therapy are highlighted. Additionally, the emerging role of systemic agents showing distinct clinical activity in patients with brain metastases are also discussed. As we continue to gain advances in systemic therapies for metastatic disease, local control of brain metastases in these patients is likely to become more critical in improving survival and quality of life, thereby calling for a more aggressive multi-modal approach to this population of patients.     

The surgical management of neuroendocrine tumour hepatic metastases

Although rare in incidence, patients with neuroendocrine tumours (NET) live for many years and so have a high prevalence, and NETs frequently metastasise to the liver (NLM). Numerous treatment options have been implemented both for cure, and to implement disease control.     

Intracranial metastases: behavioral patterns related to primary site and results of treatment by whole brain irradiation

Three hundred and fifty cases of tumors that metastasized to the brain and treated by radiotherapy were reviewed. The majority of patients had either lung (46 % I or breast (42 % ) primaries. Eighty percent of the patients had other sites of metastatic involvement. Seventy-five percent of the patients improved after cranial irradiation. The median survival was less than 6 months, regardless of the primary disease or the dose employed. No subgroup could be identified that might benefit from a more aggressive treatment regimen. Radiation treatment in the range of 2,000 rad in one week or 3,000 rad in two weeks is recommended for palliation of metastatic cancer to the brain.     

Management of solitary metastasis to the brain: The role of elective brain irradiation following complete surgical resection

We examined the records of 33 patients who presented with the clinico-radiological diagnosis of solitary brain metastasis and no other evidence of tumor dissemination. Length of survival of patients and patterns of treatment failure were analyzed according to the treatment modalities that were used, i.e., total excision alone or total excision with elective brain irradiation. Both groups were comparable regarding major parameters that affect response and survival in patients with brain metastasis. There did not appear to be any significant advantage to the use of irradiation following excision, at least at the doses employed in this study. We advocate the use of higher doses of irradiation in any curative attempt following total excision of a solitary brain metastasis. A higher incidence of subsequent spinal cord involvement by tumor was found in patients with lesions in the posterior fossa, pointing out the need for careful evaluation of the spinal cord with cerebrospinal fluid cytology and perhaps myelography prior to resection.     

单发或多发脑转移瘤的放疗疗效研究

目的 探求单发与多发脑转移瘤的合理放疗方案.方法 回顾性分析2005年7月至2008年7月收治的50例单发或多发脑转移瘤患者的资料.所有患者原发灶均得到控制,30例(联合组)采用全脑放疗+立体定向放射外科治疗,20例(单一组)采用单纯立体定向放射外科治疗.立体定向放射外科治疗处方剂量均采用45％～ 75％等剂量线包绕计划靶区,边缘剂量15～20 Gy,中心剂量30 ～45 Gy,一次完成;全脑放疗每次分割剂量为2 Gy,1次/d,5次/周,总剂量40 Gy/4周.结果 联合组有效率为90.0％ (27/30),单一组为60.0％ (12/20),联合组的有效率明显高于单一组(x2=6.294,P=0.012);联合组和单一组的1年生存率分别为50.0％ (15/30)和35.0％ (7/20),2年生存率分别为30.0％(9/30)和15.0％(3/20),两组1、2年生存率差异均无统计学意义(x2=1.096,P=0.295;x2=1.480,P=0.224),两组均无生存3年以上的患者;分层分析显示,在单发病灶患者中,两组1年生存率差异无统计学意义(100.0％∶66.7％,x2=1.556,P=0.212),在多发病灶患者中,联合组的1年生存率明显优于单一组(42.3％∶29.4％,x2 =11.023,P=0.001),在单发和多发病灶患者中,两组2年生存率差异均无统计学意义(75.0％∶66.7％,x2=1.200,P=0.273;23.1％∶5.9％,x2=3.782,P=0.052).结论 全脑放疗和立体定向放射外科是治疗单发或多发脑转移瘤的重要手段,对于单发脑转移瘤可单独行立体定向放射外科治疗,多发脑转移瘤则应行全脑放疗联合立体定向放射外科治疗.     

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.     

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.     

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。     

Stereotactic radiosurgery in the treatment of brain metastases: The current evidence

Chemotherapy has made substantial progress in the therapy of systemic cancer, but the phar-macological efficacy is insufficient in the treatment of brain metastases. Fractionated whole brain radiotherapy (WBRT) has been a standard treatment of brain metastases, but provides limited local tumor control and often unsatisfactory clinical results. Stereotactic radiosurgery using Gamma Knife, Linac or Cyberknife has overcome several of these limitations, which has influenced recent treatment recommendations. This present review summarizes the current literature of single session radiosurgery concerning survival and quality of life, specific responses, tumor volumes and numbers, about potential treatment combinations and radioresistant metastases.     

Activity of pemetrexed against brain metastases in a patient with adenocarcinoma of the lung

A 53-year-old woman was with adenocarcinoma of the lung metastatic to the brain was treated after several lines of chemotherapy with pemetrexed. After six cycles an impressive regression of the brain metastases was documented.A brief review of the literature on response of cerebral metastases to chemotherapy is added.     

脑转移瘤合理治疗模式的Meta分析

目的 应用Meta分析的方法探讨脑转移瘤的合理治疗模式.方法 以中英文关键词检索中外数据库,检索时限为自各数据库建立起至2012年12月30日.以Jadad评分评价文献质量,采用RevMan5.0软件完成统计分析.共纳入25篇文献,2 750例患者,依据不同的治疗方法进行分组.结果 与单一治疗相比,综合治疗能提高患者的1年生存率(OR =0.58,95％ CI为0.46 ～0.71,P＜0.000 01);在综合治疗组中,与2种联合治疗方式相比,3种联合治疗方式能提高患者的1年生存率(OR=0.63,95％ CI为0.50～0.80,P=0.000 1);与局部治疗相比,全身+局部治疗能提高患者的1年生存率(OR=0.68,95％ CI为0.53 ～0.86,P=0.001);与全身治疗相比,全身+局部治疗能提高患者的1年生存率(OR =0.59,95％ CI为0.41 ～0.86,P=0.006);在全身+局部治疗中,与2种联合治疗方式相比,3种联合治疗方式能提高患者的1年生存率(OR=0.52,95％ CI为0.35 ～0.78,P=0.002);与非靶向治疗相比,分子靶向药物治疗能提高患者的1年生存率(OR=0.76,95％ CI为0.67 ～0.87,P＜0.000 1).结论 脑转移瘤的合理治疗模式为手术、放疗、化疗3种治疗方式结合,即全身+局部治疗,如果具有应用分子靶向药物的指征,在原方案基础上联合分子靶向药物效果更佳.     

Whole brain irradiation following surgery or radiosurgery for solitary brain metastases: Mature results of a prematurely closed randomized Trans-Tasman Radiation Oncology Group trial (TROG 98.05)

We evaluated the effect of adjuvant whole brain irradiation (WBI) after surgery or radiosurgery for solitary brain metastases in a Phase III multicentre trial with randomization to 30-36 Gy WBI or observation. The study was closed early due to slow accrual after 19 patients (WBI 10, observation 9). There was no difference in CNS failure-free survival or overall survival between the arms. There was a trend to reduced CNS relapse with WBI (30% versus 78%, P = 0.12). Limited analysis of quality of life and neurocognitive function data revealed no evidence of difference between the arms. Our results are not inconsistent with two larger randomized trials and support the use of upfront WBI to decrease brain recurrence in this setting.     

Effectiveness of stereotactic radiosurgery alone or in combination with whole brain radiotherapy compared to conventional surgery and/or whole brain radiotherapy for the treatment of one or more brain metastases: a systematic review and meta-analysis

PURPOSE: To assess the effectiveness of SRS alone or in combination with WBRT compared to surgery and/or WBRT in prolonging survival and improving the quality-of-life and functional status of patients with brain metastases. METHODS AND MATERIALS: A meta-analysis of randomized controlled trials and concurrent cohort studies examining SRS versus SRS + WBRT, SRS versus WBRT +/- surgical resection, SRS versus surgical resection only, or SRS + WBRT versus WBRT was conducted. Trial registers, bibliographic databases, and reference lists from selected studies and recent issues of relevant journals were searched. Neuro-oncology specialists were also contacted. All studies were analyzed independently by two reviewers, applying validated critical appraisal techniques. RESULTS: The review identified three RCTs and one cohort study. Among patients with multiple metastases, no difference in survival between those treated with WBRT + SRS and those treated with WBRT was found. However, in patients with one metastasis, a statistically significant difference, favoring those treated with WBRT + SRS, was observed. Regarding local tumor control at 24 months, rates were significantly higher in the WBRT + SRS treatment arm, regardless of the number of metastases. CONCLUSIONS: Adding SRS to WBRT improves survival in patients with one brain metastasis. Combining SRS and WBRT improves local tumour control and functional independence in all patients.     

抗血管生成药物治疗肺癌脑转移的研究新进展

晚期肺癌脑转移发生率高,预后差.近年来,随着肺癌总体治疗的发展,为晚期肺癌脑转移提供了更多的治疗手段和期待.目前的临床研究提示抗血管生成药物在肺癌脑转移的治疗中占有重要地位,从大分子的单克隆抗体,到泛靶点抗血管药物,再到小分子酪氨酸激酶抑制剂(Tyrosine kinase inhibitor,TKI),均显示出一定的...