Schlienger M, Nataf F, Huguet F, Pene F, Foulquier J-N, Orthuon A, Roux F-X, Touboul E
Service d'oncologie-radiothérapie, hôpital Tenon, 4 rue de la Chine, Paris, France.
Cancer Radiother. 2010 Apr;14(2):119-27. doi: 10.1016/j.canrad.2009.10.004. Epub 2009 Dec 8.
A survey of the literature has been performed to find arguments in order to help the choice between radiosurgery and hypofractionated stereotactic radiotherapy in the treatment of brain metastases.
A comparison of two groups of brain metastases treated with hypofractionated stereotactic radiotherapy or radiosurgery, with or without WBRT was performed. Hypofractionated stereotactic radiotherapy: there were eight series including 448 patients published from 2000 to 2009; treated with 5-6 MV X-Rays, non invasive head immobilization, a margin 2 to 10mm; 24 to 40Gy in three to five fractions; a 5 to 8 days duration in six series and 15-16 days in two other series. WBRT (30%) ; radiosurgery: there were 12 series (1994 to 2005) including 2157 patients; an invasive head immobilization, no margin; doses from 10 to 25 Gy; six series over 12 had Gamma Knife radiosurgery and six had Linacs X-Rays. WBRT (30 Gy/10 F/12 days) associated to radiosurgery in several series. The following parameters were compared: median GTV, median survival, 1-year survival rate, local control rate, necrosis and WBRT rates.
Hypofractionated stereotactic radiotherapy series: the parameters were respectively: 0,52-4,47 cm(3) (median 2,8 cm(3)); 5-16 months (median 8,7 months); 68,2-93% (median 82,5%); necrosis rate 3,1%; associated WBRT 30%. Radiosurgery series: the parameters were respectively: 1,3 to 5,5 cm(3) (median 2 cm(3)); 5,5 to 22 months (median 11 months); 71 to 95% (median 85%); 0,5 to 6% (median 2,4%); associated WBRT 58%. Results seem similar in the two groups: Hypofractionated stereotactic radiotherapy with non invasive immobilization could theoretically treat all brain metastases sizes except lesions<10 mm (500 mm(3)). In large volumes,>4200 mm(3) GTV, the toxicity of hypofractionated stereotactic radiotherapy was not reported, thus it was difficult to compare its results with the published reports of radiosurgery toxicity. WBRT was a confusing parameter. Obviously, this initial survey has important limitations, specifically its methodology.
Radiosurgery and hypofractionated stereotactic radiotherapy could be used to treat brain metastases with GTV>500 mm(3) and < or = 4200 mm(3) (Ø 20mm); for GTV<500 mm(3) (Ø 10mm) an invasive procedure with radiosurgery is necessary. For GTV>4200 mm(3) (Ø 20mm), hypofractionated stereotactic radiotherapy could be proposed, provided further studies, using 4 to 6 Gy fractions, a duration less or equal to 10-12 days and a margin of 2mm will be performed.
进行文献综述以寻找论据，帮助在脑转移瘤治疗中选择放射外科手术和低分割立体定向放射治疗。
对两组接受低分割立体定向放射治疗或放射外科手术（有无全脑放疗）的脑转移瘤患者进行比较。低分割立体定向放射治疗：有8个系列，包括2000年至2009年发表的448例患者；采用5 - 6兆伏X射线治疗，非侵入性头部固定，边缘2至10毫米；分三至五次于24至40戈瑞剂量照射；六个系列疗程持续5至8天，另外两个系列为15 - 16天。全脑放疗（30%）；放射外科手术：有12个系列（1994年至2005年），包括2157例患者；采用侵入性头部固定，无边缘；剂量为10至25戈瑞；12个系列中有6个采用伽玛刀放射外科手术，6个采用直线加速器X射线。几个系列中全脑放疗（30戈瑞/10次/12天）与放射外科手术联合使用。比较以下参数：中位大体肿瘤体积、中位生存期、1年生存率、局部控制率、坏死率和全脑放疗率。
低分割立体定向放射治疗系列：参数分别为：0.52 - 4.47立方厘米（中位值2.8立方厘米）；5 - 16个月（中位值8.7个月）；68.2% - 93%（中位值82.5%）；坏死率3.1%；联合全脑放疗30%。放射外科手术系列：参数分别为：1.3至5.5立方厘米（中位值2立方厘米）；5.5至22个月（中位值11个月）；71%至95%（中位值85%）；0.5%至6%（中位值2.4%）；联合全脑放疗58%。两组结果似乎相似：采用非侵入性固定的低分割立体定向放射治疗理论上可以治疗除<10毫米（500立方毫米）病变外的所有脑转移瘤大小。在大体肿瘤体积>4200立方毫米时，未报道低分割立体定向放射治疗的毒性，因此难以将其结果与已发表的放射外科手术毒性报告进行比较。全脑放疗是一个令人困惑的参数。显然，这项初步综述有重要局限性，特别是其方法学。
放射外科手术和低分割立体定向放射治疗可用于治疗大体肿瘤体积>500立方毫米且≤4200立方毫米（直径20毫米）的脑转移瘤；对于大体肿瘤体积<500立方毫米（直径10毫米），有必要采用放射外科手术的侵入性操作。对于大体肿瘤体积>4200立方毫米（直径20毫米），可以考虑低分割立体定向放射治疗，但前提是进行进一步研究，采用4至6戈瑞分次剂量、疗程持续时间≤10 - 12天且边缘为2毫米。
