Ling Diane C, Vargo John A, Wegner Rodney E, Flickinger John C, Burton Steven A, Engh Johnathan, Amankulor Nduka, Quinn Annette E, Ozhasoglu Cihat, Heron Dwight E
*Department of Radiation Oncology, University of Pittsburgh Cancer Institute, and ‡Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Neurosurgery. 2015 Feb;76(2):150-6; discussion 156-7; quiz 157. doi: 10.1227/NEU.0000000000000584.
Postoperative stereotactic radiosurgery for brain metastases potentially offers similar local control rates and fewer long-term neurocognitive sequelae compared to whole brain radiation therapy, although patients remain at risk for distant brain failure (DBF).
To describe clinical outcomes of adjuvant stereotactic radiosurgery for large brain metastases and identify predictors of intracranial failure and their implications on optimal patient selection criteria.
We performed a retrospective review on 100 large (>3 cm) brain metastases in 99 patients managed by resection followed by postoperative stereotactic radiosurgery to a median dose of 22 Gy (range, 10-28) in 1 to 5 fractions (median, 3). Primary histology was nonsmall cell lung in 40%, breast cancer in 18%, and melanoma in 17%. Forty (40%) patients had uncontrolled systemic disease.
With a median follow-up of 12.2 months (range, 0.6-87.4), the 1-year Kaplan-Meier local control was 72%, DBF 64%, and overall survival 55%. Nine patients (9%) developed evidence of radiation injury, and 6 (6%) developed leptomeningeal disease. Uncontrolled systemic disease (P=.03), melanoma histology (P=.04), and increasing number of brain metastases (P<.001) were significant predictors of DBF on Cox multivariate analysis. Patients with <4 metastases, controlled systemic disease, and nonmelanoma primary (n=47) had a 1-year DBF of 48.6% vs 80.1% for all others (P=.01).
Postoperative stereotactic radiosurgery to the resection cavity safely and effectively augments local control of large brain metastases. Patients with <4 metastases and controlled systemic disease have significantly lower rates of DBF and are ideal treatment candidates.
与全脑放疗相比，脑转移瘤术后立体定向放射外科手术可能提供相似的局部控制率，且长期神经认知后遗症较少，尽管患者仍有远处脑衰竭（DBF）的风险。
描述辅助性立体定向放射外科手术治疗大脑大转移瘤的临床结果，并确定颅内失败的预测因素及其对最佳患者选择标准的影响。
我们对99例患者的100个大脑大转移瘤（>3 cm）进行了回顾性研究，这些患者先接受手术切除，然后进行术后立体定向放射外科手术，中位剂量为22 Gy（范围10 - 28），分1至5次照射（中位3次）。原发组织学类型中，非小细胞肺癌占40%，乳腺癌占18%，黑色素瘤占17%。40例（40%）患者存在无法控制的全身疾病。
中位随访12.2个月（范围0.6 - 87.4），1年的Kaplan-Meier局部控制率为72%，DBF为64%，总生存率为55%。9例（9%）患者出现放射损伤证据，6例（6%）发生软脑膜疾病。在Cox多因素分析中，无法控制的全身疾病（P = 0.03）、黑色素瘤组织学类型（P = 0.04）以及脑转移瘤数量增加（P < 0.001）是DBF的显著预测因素。转移瘤<4个、全身疾病得到控制且原发肿瘤为非黑色素瘤的患者（n = 47），1年DBF率为48.6%，而其他患者为80.1%（P = 0.01）。
对切除腔进行术后立体定向放射外科手术可安全有效地增强对大脑大转移瘤的局部控制。转移瘤<4个且全身疾病得到控制的患者DBF发生率显著较低，是理想的治疗对象。
