Selek Ugur, Chang Eric L, Hassenbusch Samuel J, Shiu Almon S, Lang Frederick F, Allen Pamela, Weinberg Jeffrey, Sawaya Raymond, Maor Moshe H
Department of Radiation Oncology, Brain Tumor Center, The University of Texas, M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
Int J Radiat Oncol Biol Phys. 2004 Jul 15;59(4):1097-106. doi: 10.1016/j.ijrobp.2003.12.037.
To report on the outcome of patients with melanoma brain metastases treated with stereotactic radiosurgery (SRS).
One hundred three patients with 153 intracranial melanoma metastases consecutively underwent Linac-based SRS between November 1991 and October 2001. The Kaplan-Meier method, univariate comparisons with log-rank test, and multivariate analyses with classification and regression tree models were performed. Calculations were based on last imaging date rather than the date of the last visit.
Median age was 51 years (range, 18-93 years). Median Karnofsky performance status was 90. Sixty-one patients (59%) had single brain metastasis at presentation. Treatment sequence was SRS alone (61 patients), SRS + whole-brain radiotherapy (WBRT) (12 patients), and salvage SRS after WBRT (30 patients). The median tumor volume was 1.9 cm(3) (range, 0.06-22.3 cm(3)). The median SRS minimum peripheral dose and isodose was 18 Gy (range, 10-24 Gy) and 85% (range, 60%-100%), respectively. The median follow-up was 6 months for all patients and 13 months (range, 2-46 months) for patients alive at the time of analysis. The 1-year local control (LC) for all patients treated with SRS was 49%. Among the patients treated with initial SRS alone, the 1-year LC was better for patients with tumors < or =2 cm(3) than with tumors >2 cm(3): 75.2% vs. 42.3% (p < 0.05). The 1-year distant brain metastasis-free survival incidence was 14.7% for the 73 patients receiving either initial SRS alone or SRS +WBRT. The initial number of brain lesions (single vs. multiple) was the only factor with a significant effect on distant brain metastasis-free survival at 1 year: 23.5% for single metastases and 0% for multiple lesions (p < 0.05). The 1-year overall survival was 25.2%. Stratification by Score Index for Radiosurgery (SIR) revealed a significant effect on survival, which was 29% at 1 year for SIR >6 and 10% for SIR <==6 (relative hazard ratio, 2.1; p < 0.05) in classification and regression-tree multivariate analysis involving age, Karnofsky performance status, primary tumor control, tumor volume, SRS dose, SIR (>6 vs. < or =6), and systemic disease status.
Initial SRS alone was an effective treatment modality for smaller cerebral melanoma metastases, achieving a 75% incidence of 1-year LC for < or =2 cm(3) single brain metastases and should be considered in patients with SIR >6. The role of WBRT in melanoma brain metastases cannot be addressed, owing to retrospective bias toward administering this treatment to patients with more aggressive disease. A prospective study is needed to assess the role of WBRT in patients with melanoma brain metastasis.
报告接受立体定向放射外科治疗（SRS）的黑色素瘤脑转移患者的治疗结果。
1991年11月至2001年10月期间，103例患有153处颅内黑色素瘤转移灶的患者连续接受了基于直线加速器的SRS治疗。采用Kaplan-Meier法、对数秩检验进行单因素比较以及使用分类与回归树模型进行多因素分析。计算基于末次影像学检查日期而非末次就诊日期。
中位年龄为51岁（范围18 - 93岁）。中位卡氏评分状态为90。61例（59%）患者初诊时为单发脑转移。治疗顺序为单纯SRS（61例患者）、SRS + 全脑放疗（WBRT）（12例患者）以及WBRT后挽救性SRS（30例患者）。中位肿瘤体积为1.9 cm³（范围0.06 - 22.3 cm³）。SRS的中位最小周边剂量和等剂量分别为18 Gy（范围10 - 24 Gy）和85%（范围60% - 100%）。所有患者的中位随访时间为6个月，分析时存活患者的中位随访时间为13个月（范围2 - 46个月）。接受SRS治疗的所有患者1年局部控制率（LC）为49%。在单纯接受初始SRS治疗的患者中，肿瘤体积≤2 cm³的患者1年LC优于肿瘤体积>2 cm³的患者：75.2% 对42.3%（p < 0.05）。73例单纯接受初始SRS治疗或接受SRS + WBRT治疗的患者1年无远处脑转移生存率为14.7%。初发脑转移灶数量（单发与多发）是对1年无远处脑转移生存有显著影响的唯一因素：单发转移灶患者为23.5%，多发转移灶患者为0%（p < 0.05）。1年总生存率为25.2%。根据放射外科评分指数（SIR）分层显示对生存有显著影响，在涉及年龄、卡氏评分状态、原发肿瘤控制、肿瘤体积、SRS剂量、SIR（>6对≤6）和全身疾病状态的分类与回归树多因素分析中，SIR>6的患者1年生存率为29%，SIR≤6的患者为10%（相对风险比，2.1；p < 0.05）。
单纯初始SRS是治疗较小脑黑色素瘤转移灶的有效治疗方式，对于≤2 cm³的单发脑转移灶，1年LC发生率达75%，SIR>6的患者应考虑采用该治疗方式。由于对病情更严重的患者进行该治疗存在回顾性偏差，因此无法确定WBRT在黑色素瘤脑转移中的作用。需要进行前瞻性研究以评估WBRT在黑色素瘤脑转移患者中的作用。
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