Barker Fred G, Butler William E, Lyons Sue, Cascio Ethan, Ogilvy Christopher S, Loeffler Jay S, Chapman Paul H
Proton Radiosurgery Group, Neurosurgical Service, Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
J Neurosurg. 2003 Aug;99(2):254-63. doi: 10.3171/jns.2003.99.2.0254.
The use of radiosurgery for the treatment of cerebral arteriovenous malformations (AVMs) and other lesions demands an accurate understanding of the risk of radiation-related complications. Some commonly used formulas for predicting risk are based on extrapolation from small numbers of animal experiments, pilot human treatment series, and theoretical radiobiological considerations. The authors studied the incidence of complications after AVM radiosurgery in relation to dose, volume, and other factors in a large patient series.
A retrospective review was conducted in 1329 patients with AVM treated by Dr. Raymond Kjellberg at the Harvard Cyclotron Laboratory (HCL) between 1965 and 1993. Dose and volume were obtained from HCL records, and information about patient follow up was derived from concurrent clinical records, questionnaires, and contact with referring physicians. Multivariate logistic regression with bootstrapped confidence intervals was used. Follow up was available in 1250 patients (94%); the median follow-up duration was 6.5 years. The median radiation dose was 10.5 Gy and the median treatment volume was 33.7 cm(3). Twenty-three percent of treated lesions were smaller than 10 cm(3). Fifty-one permanent radiation-related deficits occurred (4.1%). Of 1043 patients treated with a dose predicted by the Kjellberg isoeffective centile curve to have a less than 1% complication risk, 1.8% suffered radiation-related complications. Actual complication rates were 4.7% for 128 patients treated at Kjellberg risk centile doses of 1 to 1.8%, and 34% for 61 patients treated at risk centile doses of 2 to 2.5%. The fitted logistic model showed that complication risk was related to treatment dose and volume, thalamic or brainstem location, and patient age.
The Kjellberg isoeffective risk centile curve significantly underpredicted actual risks of permanent complications after proton beam radiosurgery for AVMs. Actual risks were best predicted using a model that accounted for treatment dose and volume, lesion location, and patient age.
使用放射外科治疗脑动静脉畸形（AVM）及其他病变需要准确了解辐射相关并发症的风险。一些常用的预测风险公式是基于少量动物实验、人体试验系列以及理论放射生物学考量的推断得出的。作者在一个大型患者系列中研究了AVM放射外科治疗后并发症的发生率与剂量、体积及其他因素的关系。
对1965年至1993年间在哈佛回旋加速器实验室（HCL）由雷蒙德·凯尔伯格医生治疗的1329例AVM患者进行回顾性研究。剂量和体积数据来自HCL记录，患者随访信息来自同期临床记录、问卷调查以及与转诊医生的联系。采用带有自抽样置信区间的多变量逻辑回归分析。1250例患者（94%）有随访数据；中位随访时间为6.5年。中位放射剂量为10.5 Gy，中位治疗体积为33.7 cm³。23%的治疗病变体积小于10 cm³。发生了51例永久性辐射相关缺陷（4.1%）。在1043例按照凯尔伯格等效百分位曲线预测并发症风险低于1%进行治疗的患者中，1.8%出现了辐射相关并发症。在凯尔伯格风险百分位剂量为1%至1.8%的情况下接受治疗的128例患者，实际并发症发生率为4.7%；在风险百分位剂量为2%至2.5%的情况下接受治疗的61例患者，实际并发症发生率为34%。拟合的逻辑模型显示，并发症风险与治疗剂量、体积、丘脑或脑干位置以及患者年龄有关。
凯尔伯格等效风险百分位曲线显著低估了质子束放射外科治疗AVM后永久性并发症的实际风险。使用考虑治疗剂量、体积、病变位置和患者年龄的模型能最好地预测实际风险。
