Stereotactic radiosurgery for patients with "radioresistant" brain metastases

OBJECTIVE: Our aim was to evaluate the efficacy of stereotactic radiosurgery (SRS) for the treatment of patients with brain metastases that have been determined to be "radioresistant" on the basis of histological examination. METHODS: We reviewed the medical records of 41 consecutive patients who presented with 83 brain metastases from radioresistant primaries and subsequently underwent SRS. All patients were followed until death or for a median of 31 months after SRS. Tumor histologies included renal cell carcinoma (16 patients), melanoma (23 patients), and sarcoma (2 patients). Eighteen patients (44%) had a solitary metastasis, and 23 patients (56%) had multiple metastases. RESULTS: The median overall survival time was 14.2 months after SRS. On the basis of univariate analysis, systemic disease status (P = 0.006) and Radiation Therapy Oncology Group recursive partitioning analysis (RPA) class (P = 0.005) were associated with survival. The median survival time was 23.5 months for patients in RPA Class I status and 10.5 months for patients in RPA Class II or III status. There was a trend (P = 0.12) toward improved median survival for patients with renal cell carcinoma (17.8 mo) as compared with patients with melanoma (9.7 mo). Multivariate analysis showed RPA class (P = 0.038) and histological diagnosis of primary tumor (P < 0.001) to be independent predictors for overall survival. In the 35 patients who underwent follow-up imaging, 9 (12%) of 73 tumors recurred locally. In 54% of the patients, distant brain failure (DBF) developed. Whole brain radiotherapy (WBRT) improved local control and decreased DBF, according to the univariate and multivariate analyses. Patients who received adjuvant WBRT in addition to SRS had 6-month actuarial local control of 100% as compared with 85% among those who did not receive WBRT (P = 0.018). Patients who received adjuvant WBRT with SRS had a 6-month actuarial DBF rate of 17%, as compared with a rate of 64% among patients who had SRS alone (P = 0.0027). CONCLUSION: Well-selected patients with brain metastases from radioresistant primary tumors who undergo SRS survive longer than historical controls. RPA Class I status and primary renal cell carcinoma predict longer survival. Adjuvant WBRT improves local control and decreases DBF but does not affect overall survival. Further studies are needed to determine which patients should receive WBRT.     

Outpatient brain tumor surgery: innovation in surgical neurooncology

OBJECT: Recent studies of conventional craniotomies and image-guided biopsies have afforded a solid characterization of surgical morbidity and the timing of its occurrence. This report outlines a novel 11-year experience with outpatient image-guided biopsy and outpatient craniotomy for supratentorial intraaxial brain tumors. METHODS: During the period between August 1996 and May 2007, 117 awake image-guided biopsies and 145 elective craniotomies for tumor resection were prospectively selected to be performed as outpatient procedures. Data were recorded for each patient regarding tumor histological type, reasons for admission if planned early discharge failed, and surgical complications. RESULTS: Successful discharge from the Day Surgery Unit was possible in 109 (93%) of 117 biopsy cases and 136 (94%) of 145 craniotomy cases (only 2 of which [1.5%] required unplanned readmission after discharge). Neurological worsening occurred in 5.1% of the patients who underwent image-guided biopsies, and in 5.5% of those who underwent outpatient craniotomies (based on intent-to-treat group analysis). No patient suffered an adverse event with alteration in outcome because of planned outpatient discharge. CONCLUSIONS: Outpatient image-guided brain biopsy and outpatient craniotomy for tumor resection are safe and effective procedures in selected patients.     

Resection of brain metastases previously treated with stereotactic radiosurgery

OBJECT: To date, no report has been published on outcomes of patients undergoing resection for brain metastases who were previously treated with stereotactic radiosurgery (SRS). Consequently, the authors reviewed their institutional experience with this clinical scenario to assess the efficacy of surgical intervention. METHODS: Sixty-one patients (each harboring three or fewer brain lesions), who were treated at a single institution between June 1993 and August 2002 were identified. Patient charts and their neuroimaging and pathological reports were retrospectively reviewed to determine overall survival rates, surgical complications, and recurrence rates. A univariate analysis revealed that patient preoperative recursive partitioning analysis (RPA) classification, primary disease status, preoperative Karnofsky Performance Scale score, type of focal treatment undergone for nonindex lesions, and major postoperative surgical complications were factors that significantly affected survival (p < or = 0.05). In contrast, only the RPA class and focal (conventional surgery or SRS) treatment of nonindex lesions significantly (or nearly significantly) affected survival in the multivariate analysis. Major neurological complications occurred in only 2% of patients. The median time to distant recurrence after resection was 8.4 months; that to local recurrence was not reached. The overall median survival time was 11.1 months, with 25% of patients surviving 2 or more years. Conventional surgery facilitated tapering of steroid administration. Conclusions. The complication, morbidity, survival, and recurrence rates are consistent with those seen after conventional surgery for recurrent brain metastases. Our results indicate that in selected patients with a favorable RPA class in whom nonindex lesions are treated with focal modalities, surgery can provide long-term control of SRS-treated lesions and positively affect overall survival.     

Brain dysfunction following 'awake' craniotomy,brain mapping and resection of glioma

The rationale for 'awake' resective brain tumour surgery and brain mapping is that the amount of tumour removed is optimized, and risks of damage to adjacent eloquent brain minimized by intraoperative patient assessments. Both goals are generally attained, but occasionally patients may have iatrogenic postoperative deficits. Five such cases (20%) are described from a consecutive series of 25 awake craniotomies. These patient fell into three distinct clinical categories; those (n = 2) who developed sensory-motor deficits that were recognized intraoperatively; those (n = 2) who had deficits that were apparent only on postoperative testing; and one patient who developed a sudden deficit with no warning. The former four patients had deficits that recovered within weeks to months (16%), but the latter one (4%) was left with a severe focal motor disability. These cases highlight both the benefits and limitations of awake craniotomy and intraoperative assessment. Although sensory-motor deficits can be recognized early, some high-level neurological functions may not be readily assessed intraoperatively and vascular catastrophes may occur without warning. The pathophysiological basis of these iatrogenic neurological deficits, and techniques to minimize such problems are discussed.     

Posterior fossa metastases: aggressive treatment improves survival

BACKGROUND: Brain metastases are a leading cause of mortality and morbidity in patients with malignancies. Infratentorial location has been considered a negative prognostic factor. METHODS: This retrospective study evaluated patients with cerebellar metastasis. Statistical analysis assessed age, extracranial disease, performance status and treatment. Patients were categorized by Radiation Therapy Oncology Group recursive partitioning analysis (RPA). Treatment included surgery, stereotactic radiosurgery (SRS) and whole brain radiotherapy (WBRT) alone or in combination. RESULTS: Of 93 patients, the median survival was 12.9 months for RPA class I, 11 months for class II and 8 months for class III. On multivariate analysis, RPA class was an important predictor for overall survival. However, SRS with WBRT or surgery with WBRT or a combination of SRS, surgery and WBRT, was more favorable than surgery or SRS alone within RPA class II patients. CONCLUSIONS: Survival of patients with cerebellar brain metastasis is comparable to that of patients with supratentorial brain metastasis using RPA classification. Aggressive multimodality therapy has a favorable impact on survival.     

Safety and feasibility of image-guided robotic radiosurgery for patients with limited bone metastases of prostate cancer

ObjectiveTo determine the safety and feasibility after image-guided single fraction robotic stereotactic radiosurgery (SRS) in patients with bone metastases of prostate cancer.Materials and methodsForty patients with 64 bone metastases of prostate cancer were prospectively enrolled in a single center study and underwent 54 consecutive outpatient single session SRS procedures during a 4-year period. F-18 choline PET/CT in addition to standard CT imaging was done prior to SRS in all patients. Nineteen patients were under anti-androgen therapy, 8 patients had undergone chemotherapy before SRS. Overall survival and freedom from local tumor recurrence was analyzed with the Kaplan-Meier method.ResultsMean follow-up was 14 months (3–48 months). Seventy-five percent of patients had a single bone metastasis. The median tumor volume was 13 cc. The mean prescribed tumor dose was 20.2 Gy (16.5–22 Gy). Eight patients had died at the time point of the data analysis. The actuarial 6-months, 12-months, and 24-months local tumor control rate was 95.5% (95% CI: 83.0–98.8) as measured by MRI and PET CT imaging. The median initial PSA before SRS was 5.4 ng/dl (CI: 1.4–8.2) and dropped to 2.7 ng/dl (CI: 0.14–10) after 3 months. One case of progressive neurological deficits was documented.ConclusionsThis first report on single session, image-guided robotic SRS documents a safe, feasible, and patient-friendly treatment option in selected patients with bone metastases of prostate cancer.     

Day-case neurosurgery for brain tumours: the early United Kingdom experience

Day-case biopsy and craniotomy for brain tumours have been reported as safe and feasible options for selected patients. The incidence and timing of complications after such procedures has also been characterized in recent publications. However, more widespread adoption of day-case cranial neurosurgery has not taken place. We report the first UK series of day-case surgery for intra-axial tumours, consisting of 30 image-guided biopsies and 11 craniotomies, taking place over 1 year from October 2006. Patients were studied prospectively and 27/30 biopsy and 9/11 craniotomy patients were discharged 6 h postoperatively. One biopsy case was admitted due to increased headache postoperatively, but with a normal CT and one craniotomy case had transient worsening of lower limb paresis requiring overnight admission. The three other overnight admissions were for patient preference. One biopsy patient was readmitted 30 h postoperatively with a seizure and discharged the following day. No patients suffered an adverse outcome. The results are presented together with the Toronto series of 284 cases over 11 years, also with no patients suffering an adverse outcome because of planned early discharge. These results suggest that day-case surgery for brain tumours is a safe and feasible option for patients in the UK.     

Presentation and management of gastrointestinal stromal tumors of the duodenum

Duodenal gastrointestinal stromal tumors (GIST) have been described primarily in isolated case reports. In order to learn more about duodenal GIST, a retrospective review of patients with GIST managed at a single institution between 2000 and 2005 was conducted. Thirty-eight GIST of the stomach and small bowel were analyzed. Eight (21%) were duodenal GIST. The median size of duodenal GIST (6.0 cm) and small bowel GIST (6.3 cm) was larger than the median size of gastric GIST (3.0 cm). The most common presentation of duodenal GIST was bleeding (50%) which was similar to other small bowel GIST (49%) but different from gastric GIST which were most commonly an incidental finding (62%). Two patients (25%) with duodenal GIST had a history of neurofibromatosis. The duodenal GIST were located in the 2nd (n = 5, 63%) and 3rd portion of duodenum (n = 3, 37%). Seven of 8 patients underwent complete resection of duodenal GIST. Pancreaticoduodenectomy was the most common operation performed (n = 5); 2 patients were treated with partial duodenal resection. No patients undergoing pancreaticoduodenectomy (n = 5) were found to have lymph node metastases. No patients received neo-adjuvant or adjuvant therapy with Imatinib. Following resection, 2 patients have recurred (12 and 48 mo.), 4 patients are without disease (1, 6, 6, and 24 mo.), 1 patient died postoperatively. Duodenal GIST are relatively rare tumors that present most commonly with gastrointestinal bleeding. Duodenal GIST are associated with neurofibromatosis. Many duodenal GIST require pancreaticoduodenectomy for complete removal.     

Correlation of factors predicting intraoperative brain shift with successful resection of malignant brain tumors using image-guided techniques

BACKGROUND: Intraoperative brain shift may cause inaccuracy of stereotactic image guidance on the basis of preoperatively acquired imaging data. The purpose of our study was to determine whether factors predicting brain shift affect the success of image-guided resection of malignant brain tumors. METHODS: We retrospectively studied 54 patients who underwent image-guided resections of histopathologically confirmed malignant brain tumors (9 metastases, 45 high-grade gliomas). Precautions were taken during surgery to minimize brain shift, but intraoperative imaging was not performed. The following factors predictive of intraoperative brain shift were assessed: tumor size, periventricular location, patient age, prior surgery or radiation therapy, patient positioning, use of mannitol, and length of operative time. Postoperative magnetic resonance imaging was obtained in all cases within 48 hours of surgery to assess extent of resection. RESULTS: Perioperative mortality was 0% in our series; perioperative morbidity was 3 of 54 patients (5.5%); 1 patient required reoperation for a hematoma, and 2 had transient neurological deficits. Successful resection was accomplished in 93% of tumors less than 30 cm(3) compared with 63.6% of tumors greater than 30 cm(3) (P = .026, Fisher exact test). This difference was more pronounced for patients with malignant gliomas. However, other factors predictive of intraoperative brain shift were not associated with unsuccessful resection. CONCLUSIONS: Intraoperative brain shift does not significantly affect the likelihood of successful resection of malignant brain tumors smaller than 30 cm(3). Larger tumors are less likely to be successfully resected, although factors other than brain shift can contribute to unsuccessful resection.     

Patient selection and clinical outcomes in patients operated for brain metastases - is specialty of the referring physicians a prognostic factor?

Abstract Introduction. As median survival in patients with brain metastases is short, but with wide confidence intervals, it is crucial to select the appropriate therapy. Various specialists diagnose brain metastases and refer selected patients to neurosurgical departments. There is, however, no robust and objective instrument for clinical decision making in individual patients with brain metastases. In consecutive patients treated with open surgery, we aimed to explore if clinical outcomes differed between the specialties of the referring physicians. Methods. We retrospectively included all adult (≥ 18years) patients undergoing open surgery for brain metastases from 2004 through 2009 (n = 141). We divided the specialties of referring physicians in three groups; oncologists, pulmonologists and others. Results. 59 patients (42%) were referred from oncologists, 24 (17%) referred from pulmonologists and 58 (41%) referred from other specialties. There was no significant association between the graded prognostic assessment score and clinical specialty (P = 0.366), reflecting similar referral practice. Twenty-four patients (17%) died within 3 months from surgery. There was no association between clinical specialty and 3 months mortality (P = 0.461). The perioperative mortality was 7% (n = 10), and we registered 19% (n = 27) complications. Risk of perioperative mortality (P = 0.448) or surgical complications (P = 0.330) were also not associated with the specialty of the referring clinician. Conclusion. Patient selection and clinical outcomes did not differ between the specialties of referring physicians. We believe patient selection and outcomes were fairly similar between groups as a result of the multidisciplinary work-up between referring physicians and neurosurgeons. However, with 17% 3-month mortality there is still room for improvement in patient selection.     

Treatment of spinal metastases from kidney cancer by presurgical embolization and resection

Surgical treatment of bone metastases from kidney cancer is often complicated by profuse blood loss. The authors report the results of a retrospective review of 30 consecutive patients who underwent surgery for spinal metastases from kidney cancer. Seventeen patients (57%) were operated on after failing radiation therapy. Prior to operation, selective spinal angiography and embolization were performed in 17 patients with no permanent neurological deficits resulting. Gross total resection of the tumor and stabilization of the spine were then accomplished with acceptable blood loss. Twenty-seven (90%) of the 30 patients improved neurologically following surgery. There was a median survival time of 16 months, a 2-year survival rate of 33%, and a 5-year survival rate of 15%. Major surgical complications in this series were related to excessive blood loss in patients without embolization. These data suggest that patients with spinal metastases from kidney cancer should undergo spinal angiography and embolization prior to resection of the tumor. To improve upon current results, such treatment should be carried out prior to external radiation therapy.     

Present state of anesthetic management for awake craniotomy in Japan

To avoid the neurological deficits after neurosurgical procedures, awake craniotomy applying intraoperative awake functional brain mapping has been employed. Anesthesia for awake craniotomy requires particular attention to airway management, control of seizures and measures for decreasing the anxiety of the patients. We investigated the current status of anesthetic management for awake craniotomy in Japan to establish a standard procedure for safe anesthesia. A questionnaire was sent to 80 universities with departments of anesthesia in Japan and 34 (43%) responded. In 19 institutes, awake craniotomies are being practiced. The first experience of awake craniotomy was in 1996 in Japan and since then most of the institutes have experienced only three or fewer cases. Airway management, control of nausea and vomiting, stable awakening during functional mapping and control of seizures were pointed out as problems during awake craniotomy. Based on the present results, our experience and the information from previous investigations, standard anesthetic management for awake craniotomy in our country will be documented.     

Permanent iodine-125 interstitial radiation therapy in the treatment of non-glioblastoma multiforme high-grade gliomas

BACKGROUND: This study evaluates prognostic factors influencing survival outcomes for 60 patients with permanent iodine-125 implants in the primary treatment of non-glioblastoma multiforme (GBM) high-grade gliomas. METHODS: Stereotactic treatment planning aimed to encompass the contrast-enhancing rim of the tumor visualized by CT, with an initial dose rate of 0.05 Gy/h with 125I, delivering 100 Gy at 1 year and 103.68 Gy at infinity. Survival was evaluated using the Kaplan-Meier method for univariate analysis and the Cox regressional method for multivariate analysis. In addition to the implant, 34 patients received external radiation therapy (5,000-6,000 cGy) before the implant; 13 patients were implanted without additional external beam radiation, and 13 patients underwent external radiation therapy before implant placement. RESULTS: With a mean follow-up of 77.6 months (range 3.5-164 months), 1-, 3-, 5- and 10-year survival were 86.7% (+/-0.05%), 60% (+/-0.07%), 50% (+/-0.07%) and 45.7% (+/-0.7%), respectively. The median survival time was 57 months. Second surgery was performed following the implant in 19 patients. Findings were tumor recurrence in 11 patients (22.5%), radiation necrosis in 7 patients (14.3%) and brain abscess in 1 patient (2%). Age, sex, tumor location, side of brain, tumor volume, Karnofsky score and neurological status were correlated with survival outcome. Favorable prognostic factors were age younger than 45 years, superficial tumor location and preoperative Karnofsky score greater than 70. RPA classification was used to define this group of patients. In RPA classes I and II (n = 43), 1-year survival was 93%, while 3-, 5- and 10-year survival was 67.4, 60.5 and 55.5%, respectively, and median survival time was 91 months. In RPA class III (n = 7), 1-year survival was 71.4%, while 3- and 5-year survival was 42.9 and 28.6%, respectively, and median survival time was 47 months. In RPA class IV (n = 10), 1-year survival was 60%, while 3-, 5- and 10-year survival was 50, 22.2 and 11.1%, respectively, and median survival time was 37 months. CONCLUSION: Brachytherapy with permanent implant of 125I appears promising in the treatment of primary non-GBM malignant gliomas. It improved survival time and reduced the incidence of complications and provided good quality of life. In order to further confirm these results, multicenter randomized prospective studies are needed. RPA analysis is a valid tool to define prognostically distinct survival groups. In this study, 2-year survival and median survival time were improved in all prognostic classes. This would suggest that selection bias alone does not account for the survival benefit seen with 125I implants. Further randomized studies with effective stratification are needed.     

Factors affecting the prognosis of breast cancer patients with brain metastases

The aim of this retrospective analysis was to investigate the factors affecting the prognosis of brain metastases in breast cancer patients to identify subgroups which might benefit from prophylactic treatments in future. Seventy-three early and 13 advanced stage patients with known Erb-2 status were included. In 14% of the early stage patients, the first recurrence site was isolated brain metastasis. None of the anthracycline resistant patients had brain metastases as their first recurrence site. The median interval between diagnosis and brain metastasis was 41.5 months (95% CI, 35.79-47.20) in early stage patients. The median interval between the first extracerebral metastases to the brain metastases was 15.5 months (95% CI, 12.24-18.76) in all patients. High histologic and nuclear grade, large tumor, anthracycline resistance were the factors which significantly affected the early appearance of brain metastases but only advanced age (> or =55 years, P=.035) correlated with isolated brain metastasis. Progression with isolated brain metastases was significantly higher in responsive ErbB-2 positive population (P=.036) and none of other pathological factors was associated with isolated brain metastasis in advanced stage. The median survival after brain metastasis in patients with brain metastasis as first recurrence was longer than the patients with brain metastasis after other organ metastasis (13 months vs 2 months P=.003). The median survival following brain metastases in complete responsive patients was higher than the others (24 months vs 6 months, P=.002). Therefore, response to systemic treatment was more determinative in the development of isolated brain metastases than clinical and pathologic features. ErbB-2 should be emphasized in prophylactic treatment strategies. Prophylactic cranial radiotherapy may be an effective treatment option for metastatic patients with complete responsive disease and with controlled ErbB-2 positive disease.     

The role of tumor size in the radiosurgical management of patients with ambiguous brain metastases

OBJECTIVE: To identify a size cutoff below which it is safe to observe obscure brain lesions suspected of being metastases so that treatment of nonmetastases can be avoided. METHODS: Medical records from patients who underwent linear accelerator-based radiosurgery from August 1991 to October 2001 were reviewed. Inclusion criteria were defined as brain metastasis tumor volume less than 5 cm(3) (diameter, thick similar 2.1 cm) treated with a dose of 20 Gy or more. One hundred thirty-five patients had 153 evaluable brain metastases with follow-up imaging that met inclusion criteria. Median age was 54 years (range, 18-79 yr). Lesion primaries were non-small-cell lung (n = 39), melanoma (n = 44), renal (n = 37), breast (n = 18), colon (n = 3), sarcoma (n = 5), other (n = 5), and unknown primary (n = 2). Median tumor volume was 0.67 cm(3) (range, 0.06-4.58 cm(3)). The minimum peripheral dose was 20 Gy (n = 132) or 21 to 24 Gy (n = 21). At the time of analysis, the median follow-up for all patients was 10 months (range, 0.2-99 mo). RESULTS: The 1- and 2-year actuarial local control rates for all of the lesions were 69 and 46%, respectively. For lesions of 1 cm (0.5 cm(3)) or less, the corresponding local control rates were 86 and 78%, respectively, which was significantly higher than the corresponding rates of 56 and 24%, respectively, for lesions larger than 1 cm (0.5 cm(3)) (P = 0.0016). CONCLUSION: A convincing brain metastasis measuring less than 1 cm should be pursued aggressively. If the suspected brain metastasis is ambiguous, observation is proposed up to a diameter of 1 cm. This is the first study in the literature to identify a 1-cm cutoff for radiosurgical control of small brain metastases, and validation by additional studies is required.     

Surgical treatment of primary lung cancer with synchronous brain metastases

OBJECTIVES: The role of surgical resection for brain metastases from non-small cell lung cancer is evolving. Although resection of primary lung cancer and metachronous brain metastases is superior to other treatment modalities in prolonging survival and disease-free interval, resection of the primary non-small cell lung cancer and synchronous brain metastases is controversial. METHODS: From January 1975 to December 1997, 220 patients underwent surgical treatment for brain metastases from non-small cell lung cancer at our institution. Twenty-eight (12.7%) of these patients underwent surgical resection of synchronous brain metastases and the primary non-small cell lung cancer. RESULTS: The group comprised 18 men and 10 women. Median age was 57 years (range 35-71 years). Twenty-two (78.6%) patients had neurologic symptoms. Craniotomy was performed first in all 28 patients. Median time between craniotomy and thoracotomy was 14 days (range 4-840 days). Pneumonectomy was performed in 4 patients, bilobectomy in 4, lobectomy in 18, and wedge excision in 2. Postoperative complications developed in 6 (21.4%) patients. Cell type was adenocarcinoma in 11 patients, squamous cell carcinoma in 9, and large cell carcinoma in 8. After pulmonary resection, 17 patients had no evidence of lymph node metastases (N0), 5 had hilar metastases (N1), and 6 had mediastinal metastases (N2). Twenty-four (85.7%) patients received postoperative adjuvant therapy. Follow-up was complete in all patients for a median of 24 months (range 2-104 months). Median survival was 24 months (range 2-104). Survival at 1, 2, and 5 years was 64.3%, 54.0%, and 21.4%, respectively. The presence of thoracic lymph node metastases (N1 or N2) significantly affected 5-year survival (P =.001). CONCLUSION: Although the overall survival for patients who have brain metastases from non-small cell lung cancer is poor, surgical resection may prove beneficial in a select group of patients with synchronous brain metastases and lung cancer without lymph node metastases.     

大肠癌脑转移的临床特征及其手术治疗

目的 分析大肠癌脑转移的临床特征及其手术治疗转归. 方法回顾性分析手术治疗的大肠癌伴脑转移28例患者的临床资料,统计数据采用单因素Log-Rank分析和多因素Cox回归分析法.结果 大肠癌继发脑转移的中位年龄为57(41～75)岁,原发肿瘤与转移瘤间隔的中位时间为13.5个月,其中合并颅外(肺、肝、骨)转移占61%(17/28),仅有脑转移的占39%(11/28).脑转移瘤主要表现为头痛、呕吐等颅内压升高征候群和偏瘫、下肢乏力、失语等定位症状以及癫痫等,颅内转移瘤以单发病灶为多见,占82%(23/28),位于幕上(枕叶、顶叶、额叶)者占57%(16/28),位于幕下(小脑)者占43%(12/28);转移性脑瘤手术切除后中位生存时间为9.4个月,1年生存率为28.9%,5年生存率为7.1%.多因素分析提示颅内单发病灶转移(χ2=7.35,P<0.05)和无颅外其他部位转移(χ2=6.47,P<0.05)是大肠癌脑转移预后的独立影响因素.28例均接受手术切除和多学科协作治疗,无手术死亡和出血及再手术病例.结论 大肠癌脑转移总体预后欠佳,手术切除脑转移病灶可延长部分患者的存活时间.     

The role of surgical resection in the management of brain metastasis: a 17-year longitudinal study

Background

Advancements over the past generation have yielded several new treatment options for the management of brain metastases. However, surgical resection (SR) still remains the mainstay of treatment and is performed especially if decompression is required. The goal of this study was to evaluate the role of surgical resection for patients with brain metastases and to find the best indications for SR.

Methods

SR as an initial treatment was performed in 157 patients. Among the 157 patients, 109 (69.4 %) and 17 (10.8 %) underwent adjuvant whole-brain radiotherapy and radiosurgery, respectively. Thirty-one (19.7 %) patients did not undergo adjuvant treatment. Overall survival, tumour recurrence, and clinical outcomes were evaluated. The clinical situation was classified based on the recursive partitioning analysis (RPA) class and Karnofsky performance scale (KPS).

Results

The overall median survival was 19.3 months. Median survival according to the extent of surgical resection was 20.4 months after gross total resection (GTR) and 15.1 months after subtotal resection (STR) (P?=?0.016). The patients with stable primary extracranial cancer survived longer than patients with synchronous detection of extracranial cancer (P?=?0.032). The RPA I class patients showed longer survival than the RPA II class patients (P?=?0.047). This difference was more prominent in the GTR group than in the STR group (GTR, P?=?0.022; STR, P?=?0.075). The KPS score of the GTR group changed from 82.3 to 87.0 and that of the STR group changed from 79.2 to 77.1 (P?=?0.001). Adjuvant treatment did not lead to a significant improvement in the survival and clinical outcome.

Conclusions

Surgical resection may accomplish satisfactory outcomes with technical advancement. The best indications for SR for brain metastasis are RPA I class, stable extracranial cancer, and a planned GTR of the tumour. Even with the advancements in adjuvant therapy, surgical resection plays a major role in the management of brain metastasis.     

大肠癌脑转移的临床特征及其手术治疗

目的 分析大肠癌脑转移的临床特征及其手术治疗转归. 方法回顾性分析手术治疗的大肠癌伴脑转移28例患者的临床资料,统计数据采用单因素Log-Rank分析和多因素Cox回归分析法.结果 大肠癌继发脑转移的中位年龄为57(41～75)岁,原发肿瘤与转移瘤间隔的中位时间为13.5个月,其中合并颅外(肺、肝、骨)转移占61%(17/28),仅有脑转移的占39%(11/28).脑转移瘤主要表现为头痛、呕吐等颅内压升高征候群和偏瘫、下肢乏力、失语等定位症状以及癫痫等,颅内转移瘤以单发病灶为多见,占82%(23/28),位于幕上(枕叶、顶叶、额叶)者占57%(16/28),位于幕下(小脑)者占43%(12/28);转移性脑瘤手术切除后中位生存时间为9.4个月,1年生存率为28.9%,5年生存率为7.1%.多因素分析提示颅内单发病灶转移(χ2=7.35,P<0.05)和无颅外其他部位转移(χ2=6.47,P<0.05)是大肠癌脑转移预后的独立影响因素.28例均接受手术切除和多学科协作治疗,无手术死亡和出血及再手术病例.结论 大肠癌脑转移总体预后欠佳,手术切除脑转移病灶可延长部分患者的存活时间.     

大肠癌脑转移的临床特征及其手术治疗

目的 分析大肠癌脑转移的临床特征及其手术治疗转归. 方法回顾性分析手术治疗的大肠癌伴脑转移28例患者的临床资料,统计数据采用单因素Log-Rank分析和多因素Cox回归分析法.结果 大肠癌继发脑转移的中位年龄为57(41～75)岁,原发肿瘤与转移瘤间隔的中位时间为13.5个月,其中合并颅外(肺、肝、骨)转移占61%(17/28),仅有脑转移的占39%(11/28).脑转移瘤主要表现为头痛、呕吐等颅内压升高征候群和偏瘫、下肢乏力、失语等定位症状以及癫痫等,颅内转移瘤以单发病灶为多见,占82%(23/28),位于幕上(枕叶、顶叶、额叶)者占57%(16/28),位于幕下(小脑)者占43%(12/28);转移性脑瘤手术切除后中位生存时间为9.4个月,1年生存率为28.9%,5年生存率为7.1%.多因素分析提示颅内单发病灶转移(χ2=7.35,P<0.05)和无颅外其他部位转移(χ2=6.47,P<0.05)是大肠癌脑转移预后的独立影响因素.28例均接受手术切除和多学科协作治疗,无手术死亡和出血及再手术病例.结论 大肠癌脑转移总体预后欠佳,手术切除脑转移病灶可延长部分患者的存活时间.