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.     

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.     

Whole-brain radiotherapy versus stereotactic radiosurgery for patients in recursive partitioning analysis classes 1 and 2 with 1 to 3 brain metastases

BACKGROUND: The authors investigated whether stereotactic radiosurgery (SRS) alone improved outcomes for patients in recursive partitioning analysis (RPA) Classes 1 and 2 who had 1 to 3 brain metastases compared with whole-brain radiotherapy (WBRT). METHODS: Data regarding 186 patients in RPA Classes 1 and 2 who had 1 to 3 brain metastases and who received either 30 to 40 grays (Gy) of WBRT (n = 91 patients) or 18 to 25 Gy SRS (n = 95 patients) were analyzed retrospectively. Eight other potential prognostic factors were evaluated regarding overall survival (OS), entire brain control (BC), local control (LC) of treated metastases, and brain control distant from treated metastases (distant control [DC]): Those 8 factors were age, sex, performance status, tumor type, number of brain metastases, extracranial metastases, RPA class, and interval from tumor diagnosis to radiotherapy. RESULTS: On multivariate analysis of OS, age ( risk ratio [RR], 1.51; P = .024), Karnofsky performance status (KPS) (RR, 1.98; P = .002), and extracranial metastases (RR, 2.26; P < .001) were significant, whereas the radiation regimen was not significant (P = .89). On multivariate analysis of BC, only the radiation regimen (RR, 1.33; P = .003) was found to be significant. On multivariate analysis of LC, radiation regimen (RR, 1.63; P < .001) and sex (RR, 1.62; P = .022) were significant. On multivariate analysis of DC, KPS (RR, 1.85; P = .049) and extracranial metastases (RR, 1.69; P = .047) were significant. The radiation regimen was not found to be significant even on univariate analysis (P = .80). In RPA class subgroup analyses, BC and LC were better after SRS than WBRT for patients in RPA Classes 1 and 2, whereas OS and DC did not differ significantly. CONCLUSIONS: For patients in RPA Classes 1 and 2 who had 1 to 3 brain metastases, SRS alone was associated with improved BC and LC compared with 30 to 40 Gy WBRT, whereas OS and DC were not significantly different. Similar results were observed in separate subgroup analyses of patients in RPA Class 1 and RPA Class 2.     

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.     

非小细胞肺癌脑转移患者全脑放疗不同剂量预后分析

目的:分析非小细胞肺癌(NSCLC)脑转移患者不同全脑放疗(WBRT)剂量的预后及影响因素。方法:回顾性分析2013—2015年间于河北医科大学第四医院行WBRT的244例NSCLC脑转移患者。按照不同WBRT剂量(EQD 2Gy)分为30~39 Gy组104例、≥40 Gy组140例。比较两组患者颅内无进...     

Reduction of overall treatment time in patients irradiated for more than three brain metastases

PURPOSE: Patients with multiple brain metastases usually receive whole brain radiotherapy (WBRT). A dose of 30 Gy in 10 fractions (10 x 3 Gy) in 2 weeks is the standard treatment in many centers. Regarding the poor survival of these patients, a shorter RT regimen would be preferable if it provides a similar outcome as that with 10 x 3 Gy. This study compared 20 Gy in five fractions (5 x 4 Gy) within 5 days to 10 x 3 Gy. METHODS AND MATERIALS: Data from 442 patients treated with WBRT for multiple brain metastases were retrospectively analyzed. Survival and local control within the brain of 232 patients treated with 5 x 4 Gy were compared with the survival and local control within the brain of 210 patients treated with 10 x 3 Gy. Seven additional potential prognostic factors were investigated: age, gender, Karnofsky performance score, tumor type, interval from tumor diagnosis to RT, extracranial metastases, and recursive partitioning analysis class. RESULTS: On univariate analysis, the WBRT program was not associated with survival (p = 0.29) or local control (p = 0.07). On multivariate analyses, improved survival was associated with a lower recursive partitioning analysis class (p < 0.001), age or=70 (p = 0.015), and the absence of extracranial metastases (p = 0.005). Improved local control was associated with a lower recursive partitioning analysis class (p < 0.001), Karnofsky performance score >or=70 (p < 0.001), and breast cancer (p = 0.043). Grade 3 acute toxicity rates were not significantly different between 5 x 4 Gy and 10 x 3 Gy. CONCLUSIONS: Shorter course WBRT with 5 x 4 Gy was associated with similar survival and local control as "standard" WBRT with 10 x 3 Gy in patients with more than three brain metastases. The 5 x 4-Gy regimen appears preferable for most of these patients, because it is less time consuming and more convenient for patients than the 10 x 3-Gy regimen.     

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.     

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。      

A prognostic index that predicts outcome following palliative whole brain radiotherapy for patients with metastatic malignant melanoma

To determine the outcome of patients with metastatic malignant melanoma (MMM) treated with palliative whole brain radiotherapy (WBRT) and to identify factors that predict treatment outcome to assist future trial design, a retrospective study was performed on patients with MMM who received WBRT at the Royal Marsden Hospital between 1998 and 2003. Data regarding patient factors, tumour factors and survival were collected. A total of 112 patients were identified and full data were available for 102 patients. The median age was 53 years (range 25-81 years), 66.7% were male and 33.3% female. The median dose prescribed was 20 Gy in five fractions as a mid-plane dose. The median survival after WBRT for the whole group was 51 days (range 3-1386). In an attempt to define prognostic groups, we used the validated RTOG recursive partitioning analysis (RPA) classification for brain metastasis (class 1: Karnofsky Performance Score (KPS) >/=70%, age <65 years with no extracranial metastasis; class 3: KPS <70%; class 2: all others). The median survivals were 151, 71 and 21 days for RPA class 1, 2 and 3, respectively (P<0.001). Multivariate analysis showed that RPA class, leptomeningeal involvement, presence and number of extracranial metastatic sites and progressive disease in the brain on imaging before WBRT are important independent predictive factors. A prognostic index was derived from these factors that allowed identification of patients unlikely to benefit from WBRT. In conclusion, the RTOG RPA classification is valid when applied to patients with MMM. Patients in RPA class 1 and good prognosis class 2 are likely to benefit from palliative WBRT and should be considered for entry into trials that aim to improve duration of response. We identified that patients with RPA class 3, leptomeningeal involvement or RPA class 2 with poor prognostic index are unlikely to benefit from palliative WBRT.     

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。     

288例非小细胞肺癌脑转移全脑放射治疗的预后因素分析

[目的]分析影响接受全脑放射治疗的非小细胞肺癌脑转移患者的预后因素;对比评估RPA和GPA两种预后指数对临床及研究的指导意义。[方法]回顾性分析2006年1月～2008年8月在我科接受全脑放射治疗的288例非小细胞肺癌脑转移患者的临床资料,以Kaplan—Meier法计算生存率．采用多因素Cox回归法分析影响生存预后的各种因素。根据RPA和GPA两种预后指数分别建立预后模型,并分析模型中各亚组生存曲线的差异,各亚组生存率差异的比较采用Log-Rank检验。[结果]各组患者随访时间为1-33个月,其中接受全脑放射治疗后的中位生存期为8个月（95％CI：7．07～8．92个月）。多因素分析显示放射治疗前的KPS评分、原发肿瘤控制情况、年龄、脑转移灶数目、颅外转移情况、分子靶向药物治疗情况是影响生存率的独立预后因素。根据RPA和GPA指数建立的预后模型,各亚组生存曲线的差异均有统计学意义（P〈0．001）。[结论]KPS评分、原发肿瘤控制情况、年龄、脑转移灶数目、颅外转移情况、分子靶向药物治疗情况是影响非小细胞肺癌脑转移全脑放射治疗生存率的独立预后因素．RPA和GPA两种预后指数模型均能较好地反映预后。     

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。     

大分割立体定向放射治疗对非小细胞肺癌脑转移瘤的疗效评估

背景与目的：立体定向放疗（stereotacticradiotherapv,SRT）与全脑放疗（wholebrainradiationtherapy’WBRT）是治疗脑转移瘤的主要手段。本文旨在探讨伽玛射线大分割SRT加或不加WBRT对肺癌有限脑转移瘤治疗的疗效。方法：回顾性分析非小细胞肺癌多发脑转移瘤（1～4枚）患者66例,其中单纯SRT30例,SRT＋WBRT36例。分析两组患者的临床特征并应用Kaplan-Meier法计算生存率．用Logrank法对各因素进行预后分析。结果：两组患者的临床特点无明显区别：SRT组与WBRT＋SRT组的中位生存期（MST）分别为12．1与1313个月,二者无显著性差异（P=0．216）。Logrank分析显示卡氏评分（P=0．017）和颅外病变的控制情况（P=0．032）是影响预后的主要因素。结论：SRT是非小细胞肺癌有限脑转移瘤患者有效治疗手段．单纯SRT可取得与WBRT＋SRT相似的生存期．     

立体定向放疗与全脑放疗在多发脑转移瘤治疗中的作用分析

目的 总结立体定向放疗(SRT)加或不加全脑放疗(WBRT)治疗多发脑转移瘤的结果,探讨WBRT和SRT在多发脑转移瘤治疗中的作用。方法 1995—2010年收治的98例新诊断的多发(2~13个病灶)脑转移瘤患者。单纯SRT44例,WBRT加SRT54例。剂量分割模式依据转移瘤部位、体积及是否WBRT。用Kaplan-Meier法计算生存率,Cox回归模型进行各因素预后分析。中位生存期(MST)为从脑转移瘤放疗开始至各种原因所致死亡的时间的中位数。结果 全组患者中位随访时间12个月,随访率为100%。全组MST为13.5个月,其中SRT组、WBRT加SRT组的分别为13.0、13.5个月(χ²=0.31,P=0.578)。多因素分析显示仅卡氏评分(χ²=6.25,P=0.012)、原发灶诊断及脑转移瘤诊断间隔时间(χ²=7.34,P=0.025)和颅外病变情况(χ²=4.20,P=0.040)是预后因素。结论 SRT是多发脑转移瘤患者有效治疗手段,单纯SRT可取得与WBRT加SRT相似的生存期。首程SRT可能是多发脑转移瘤患者的另一治疗选择。     

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。     

Hypofractionated stereotactic radiotherapy in combination with whole brain radiotherapy for brain metastases

BACKGROUND: The efficacy and toxicity of hypofractionated stereotactic radiotherapy (HSRT) in combination with whole brain radiotherapy (WBRT), for the treatment of 1-4 brain metastases, using a non invasive fixation of the skull, was investigated. METHODS: Between 04/2001 and 01/2006 30 patients with 44 brain metastases underwent irradiation. Every patient received WBRT (10 x 3 Gy); 41/44 lesions received HSRT boost with a median dose fraction of 6 Gy, the fractionation schemes were 3 x 6 Gy and 4 x 8 Gy; a median total dose of 18 Gy was delivered to the tumor isocenter. RESULTS: The median survival period was 9.15 months, the actuarial 1-year overall survival and freedom from new brain metastases were 36.6% and 87.9%, respectively; at univariate analysis Karnofsky Performance Status (KPS) was statistically significant (P = 0.05); the actuarial 1-year local control for the 41/44 lesions was 86.1%. No patient had acute or late complications. CONCLUSIONS: HSRT as a concomitant boost during WBRT is a safe and well tolerated treatment for selected patients with brain metastases.     

Whole brain irradiation and temozolomide based chemotherapy in melanoma brain metastases

Introduction Whole brain irradiation (WBRT) remains a recommended treatment for patients with brain metastases from malignant melanoma in terms of symptom palliation, especially when extracranial systemic disease is present. Temozolomide (TMZ) has shown efficacy in the treatment of metastatic melanoma. The objective was to evaluate the potential benefit in survival of two different schedules of total dose and fractionation (20 Gy/5 fractions vs 30 Gy/10 fractions) and further TMZ based chemotherapy. Materials and method We have conducted a retrospective study in a group of twenty-one patients (RTOG Recursive Partitioning Analysis class II) of the use of WBRT with 20 Gy/5 fractions (n=11) and 30 Gy/10 fractions (n=10). All patients received further TMZ based chemotherapy administered as a single chemotherapeutic agent or in combination with chemo-immunotherapy. Results Prognostic variables such as: age, Karnofsky performance status, extracranial metastases and number of brain metastases, were analyzed in both groups of treatment without statistically significant differences. The median survival time (MST) for WBRT 20 Gy group was 4 months (CI 95%: range 2–6 months) and for WBRT 30 Gy group was 4 months (CI 95%: range 0–7 months) without statistically significant differences (Log rank p=0.74). There was one complete response and two partial responses. Conclusions The results suggest that MST was not significantly affected by the total dose/fractionation schedule.     

非小细胞肺癌 3~5个脑转移瘤优选调强放疗的可行性研究

目的 探讨调强放疗(IMRT)技术治疗非小细胞肺癌 3~5个脑转移瘤的优势。     

Systemic treatment after whole-brain radiotherapy may improve survival in RPA class II/III breast cancer patients with brain metastasis

Whole brain radiotherapy (WBRT) is the most widely used treatment for brain metastasis (BM), especially for patients with multiple intracranial lesions. The purpose of this study was to examine the efficacy of systemic treatments following WBRT in breast cancer patients with BM who had different clinical characteristics, based on the classification of the Radiation Therapy Oncology Group recursive partitioning analysis (RPA) and the breast cancer-specific Graded Prognostic Assessment (Breast-GPA). One hundred and one breast cancer patients with BM treated between 2006 and 2010 were analyzed. The median interval between breast cancer diagnosis and identification of BM in the triple-negative patients was shorter than in the luminal A subtype (26 vs. 36 months, respectively; P = 0.021). Univariate analysis indicated that age at BM diagnosis, Karnofsky performance status/recursive partitioning analysis (KPS/RPA) classes, number of BMs, primary tumor control, extracranial metastases and systemic treatment following WBRT were significant prognostic factors for overall survival (OS) (P < 0.05). Multivariate analysis revealed that KPS/RPA classes and systemic treatments following WBRT remained the significant prognostic factors for OS. For RPA class I, the median survival with and without systemic treatments following WBRT was 25 and 22 months, respectively (P = 0.819), while for RPA class II/III systemic treatments significantly improved OS from 7 and 2 months to 11 and 5 months, respectively (P < 0.05). Our results suggested that triple-negative patients had a shorter interval between initial diagnosis and the development of BM than luminal A patients. Systemic treatments following WBRT improved the survival of RPA class II/III patients.