[老年患者脑转移瘤的立体定向放射治疗]

Noël Georges, Noël Sophie, Feuvret Loïc, Valery Charles-Ambroise, Cornu Philippe, Boisserie Gilbert, Hasboun Dominique, Tep Bernadette, Delattre Jean-Yves, Baillet François, Mazeron Jean-Jacques

Service des tumeurs, Groupe Pitié-Salpêtrière, AP-HP, 47-83, bd de l'hôpital, 75651 Paris.

Bull Cancer. 2003 Oct;90(10):896-904.

AIMS

Analysis of results of stereotactic irradiation for brain metastases for patients older than 70 years.

PATIENTS AND METHODS

From January 1994 to January 2002, 53 patients received stereotactic irradiation for a total of 105 brain metastases. There were 26 females and 27 males. Median age was 73 years (70-86). Median interval between cancer diagnosis and brain metastases was 18 months (0-216). Metastases were diagnosed after development of related clinical symptoms in 34 patients (64.1%). Patients were irradiated for one to 6 metastases. Twenty-nine patients (54.7%) were treated for only one metastasis. Median metastasis diameter and volume were respectively 24 mm (5-74.9 mm) and 2.1 cc (0.02-71.3). Eighty-three metastases were supratentorial (79%), and 22 subtentorial (21%). Forty-five underwent only one procedure (85%) and 8 patients underwent a second procedure for one or several new metastases. Three patients were irradiated with whole brain radiotherapy (WBRT) concomitantly of radiosurgery and three patients received WBRT after radiosurgery for development of more than four metastases or for carcinomatous meningitis.

RESULTS

The median follow-up was 8 months (1-33). Median minimum and maximum doses delivered to the metastases were respectively, 16.42 Gy (6.5-20.5) and 20.36 Gy (13.2-41.9). The median overall survival duration was 9 months. Three-, 6-, 12- and 18-month overall survival rates were respectively, 85.6% +/- 5, 65.2% +/- 7.1, 35.5% +/- 7.8 and 26.6% +/- 8. According to unifactorial analysis, two prognostic factors of overall survival were retrieved, extra-cranial disease status and RPAa (Recursive Partitioning Analysis for aged patients) separated in three classes including Karnofsky index performance status and extra-cranial disease status, respectively p = 0.043 et p = 0.016. According to multifactorial analysis only RPAa was an independent prognostic factor of overall survival (p = 0.019, RR: 0.89, 95% confidence interval [0.017-0.47]). Median brain disease-free survival was 12 months. Three-, 6-, 12- and 18-month free-brain disease survival rates were, 81.5% +/- 6.4, 68.7% +/- 8, 47.2% +/- 9.9 and 35.4% +/- 12.6, respectively. No prognostic factor of free-brain disease survival was retrieved. Crude local control rate was 97%. Only three metastases relapsed. Six and 12-month local control rates were 98.6% +/- 1.4 and 88.5% +/- 7.6. Among 34 patients with initial clinical symptoms, one patient presented an aggravation, 9 improved up to complete response (26.5%), 13 patients presented a partial remission (38.2%) and 5 were stabilized (14.7%). For 6 patients, data were not available. We observed 3 radionecroses and 1 hemorrhage of the metastases.

CONCLUSION

Radiosurgery in the elderly was efficient and well tolerated. Age alone should not be used to deny potentially beneficial radiosurgery to any patient with brain metastases.

目的

分析70岁以上脑转移瘤患者立体定向放射治疗的结果。

患者与方法

1994年1月至2002年1月，53例患者接受立体定向放射治疗，共治疗105个脑转移瘤。其中女性26例，男性27例。年龄中位数为73岁（70 - 86岁）。癌症诊断与脑转移瘤之间的间隔时间中位数为18个月（0 - 216个月）。34例患者（64.1%）在出现相关临床症状后确诊为转移瘤。患者接受1至6个转移瘤的放射治疗。29例患者（54.7%）仅接受1个转移瘤的治疗。转移瘤直径和体积的中位数分别为24毫米（5 - 74.9毫米）和2.1立方厘米（0.02 - 71.3立方厘米）。83个转移瘤位于幕上（79%），22个位于幕下（21%）。45例患者仅接受了一次治疗（85%），8例患者因一个或多个新的转移瘤接受了第二次治疗。3例患者在立体定向放射外科治疗的同时接受了全脑放疗（WBRT），3例患者在立体定向放射外科治疗后因出现4个以上转移瘤或癌性脑膜炎接受了WBRT。

结果

中位随访时间为8个月（1 - 33个月）。转移瘤接受的最小和最大剂量中位数分别为16.42 Gy（6.5 - 20.5）和20.36 Gy（13.2 - 41.9）。总生存时间中位数为9个月。3个月、6个月、12个月和18个月的总生存率分别为85.6%±5、65.2%±7.1、35.5%±7.8和26.6%±8。单因素分析显示，总生存的两个预后因素为颅外疾病状态和RPAa（老年患者递归分区分析），RPAa分为三类，包括卡诺夫斯基指数表现状态和颅外疾病状态，p值分别为0.043和0.016。多因素分析显示，只有RPAa是总生存的独立预后因素（p = 0.019，RR：0.89，95%置信区间[0.017 - 0.47]）。脑无病生存时间中位数为12个月。3个月、6个月、12个月和18个月的无脑转移瘤生存率分别为81.5%±6.4、68.7%±8、47.2%±9.9和35.4%±12.6。未发现无脑转移瘤生存的预后因素。粗局部控制率为97%。仅3个转移瘤复发。6个月和12个月的局部控制率分别为98.6%±1.4和88.5%±7.6。在34例有初始临床症状的患者中，1例病情加重，9例改善至完全缓解（26.5%），13例部分缓解（38.2%），5例病情稳定（14.7%）。6例患者的数据未提供。我们观察到3例转移瘤放射性坏死和1例出血。