Shen Colette J, Lim Michael, Kleinberg Lawrence R
Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 401 North Broadway, Suite 1440, Baltimore, MD, 21287, USA.
Department of Neurosurgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps Suite 123, Baltimore, MD, 21287, USA.
Curr Treat Options Oncol. 2016 Sep;17(9):46. doi: 10.1007/s11864-016-0423-3.
With the development of therapies that improve extracranial disease control and increase long-term survival of patients with metastatic cancer, effective treatment of brain metastases while minimizing toxicities is becoming increasingly important. An expanding arsenal that includes surgical resection, whole brain radiation therapy, radiosurgery, and targeted systemic therapy provides multiple treatment options. However, significant controversies still exist surrounding appropriate use of each modality in various clinical scenarios and patient populations in the context of cancer care strategies that control systemic disease for increasingly longer periods of time. While whole brain radiotherapy alone is still a reasonable and standard option for patients with multiple metastases, several randomized trials have now revealed that survival is maintained in patients treated with radiosurgery or surgery alone, without upfront whole brain radiotherapy, for up to four brain metastases. Indeed, recent data even suggest that patients with up to 10 metastases can be treated with radiosurgery alone without a survival detriment. In an era of dramatic advances in targeted and immune therapies that control systemic disease and improve survival but may not penetrate the brain, more consideration should be given to brain metastasis-directed treatments that minimize long-term neurocognitive deficits, while keeping in mind that salvage brain therapies will likely be more frequently required. Less toxic therapies now also allow for concurrent delivery of systemic therapy with radiosurgery to brain metastases, such that treatment of both extracranial and intracranial disease can be expedited, and potential synergies between radiotherapy and agents with central nervous system penetration can be harnessed.
随着改善颅外疾病控制并提高转移性癌症患者长期生存率的治疗方法的发展，在将毒性降至最低的同时有效治疗脑转移瘤变得越来越重要。包括手术切除、全脑放射治疗、放射外科手术和靶向全身治疗在内的不断扩充的治疗手段提供了多种治疗选择。然而，在癌症治疗策略中，在不同临床场景和患者群体中合理使用每种治疗方式，以控制全身疾病更长时间，仍存在重大争议。虽然单独全脑放疗仍是多发转移患者合理的标准选择，但多项随机试验现已表明，对于多达四处脑转移瘤的患者，单独接受放射外科手术或手术治疗，不进行前期全脑放疗，生存率也能维持。事实上，最近的数据甚至表明，多达10处转移瘤的患者可以单独接受放射外科手术治疗而不影响生存率。在靶向和免疫治疗取得巨大进展的时代，这些治疗可控制全身疾病并提高生存率，但可能无法穿透血脑屏障，因此应更多考虑采用能将长期神经认知缺陷降至最低的脑转移瘤定向治疗方法，同时要记住可能更频繁地需要挽救性脑治疗。毒性较小的治疗方法现在还允许在对脑转移瘤进行放射外科手术的同时进行全身治疗，从而加快颅外和颅内疾病的治疗，并利用放疗与可穿透中枢神经系统的药物之间的潜在协同作用。
