单纯单次分割立体定向放射外科治疗（SRS）与手术切除联合SRS治疗大脑大转移瘤的多机构分析
Single-Fraction Stereotactic Radiosurgery (SRS) Alone Versus Surgical Resection and SRS for Large Brain Metastases: A Multi-institutional Analysis.
作者信息
Prabhu Roshan S, Press Robert H, Patel Kirtesh R, Boselli Danielle M, Symanowski James T, Lankford Scott P, McCammon Robert J, Moeller Benjamin J, Heinzerling John H, Fasola Carolina E, Asher Anthony L, Sumrall Ashley L, Buchwald Zachary S, Curran Walter J, Shu Hui-Kuo G, Crocker Ian, Burri Stuart H
机构信息
Southeast Radiation Oncology Group, Levine Cancer Institute, Charlotte, North Carolina.
Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia.
出版信息
Int J Radiat Oncol Biol Phys. 2017 Oct 1;99(2):459-467. doi: 10.1016/j.ijrobp.2017.04.006. Epub 2017 Apr 11.
PURPOSE
Stereotactic radiosurgery (SRS) dose is limited by brain metastasis (BM) size. The study goal was to retrospectively determine whether there is a benefit for intracranial outcomes and overall survival (OS) for gross total resection with single-fraction SRS versus SRS alone for patients with large BMs.
METHODS AND MATERIALS
A large BM was defined as ≥4 cm (2 cm in diameter) prior to the study. We reviewed the records of consecutive patients treated with single-fraction SRS alone or surgery with preoperative or postoperative SRS between 2005 and 2013 from 2 institutions.
RESULTS
Overall, 213 patients with 223 treated large BMs were included; 66 BMs (30%) were treated with SRS alone and 157 (70%) with surgery and SRS (63 preoperatively and 94 postoperatively). The groups (SRS vs surgery and SRS) were well balanced except regarding lesion volume (median, 5.9 cm vs 9.6 cm; P<.001), median number of BMs (1.5 vs 1, P=.002), median SRS dose (18 Gy vs 15 Gy, P<.001), and prior whole-brain radiation therapy (33% vs 5%, P<.001). The local recurrence (LR) rate was significantly lower with surgery and SRS (1-year LR rate, 36.7% vs 20.5%; P=.007). There was no difference in radiation necrosis (RN) by resection status, but there was a significantly increased RN rate with postoperative SRS versus with preoperative SRS and with SRS alone (1-year RN rate, 22.6% vs 5% and 12.3%, respectively; P<.001). OS was significantly higher with surgery and SRS (2-year OS rate, 38.9% vs 19.8%; P=.01). Both multivariate adjusted analyses and propensity score-matched analyses demonstrated similar results.
CONCLUSIONS
In this retrospective study, gross total resection with SRS was associated with significantly reduced LR compared with SRS alone for patients with large BMs. Postoperative SRS was associated with the highest rate of RN. Surgical resection with SRS may improve outcomes in patients with a limited number of large BMs compared with SRS alone. Further studies are warranted.
目的
立体定向放射外科（SRS）剂量受脑转移瘤（BM）大小限制。本研究的目标是回顾性确定对于大体积BM患者，单纯单次分割SRS与联合SRS的全切除手术相比，在颅内预后和总生存期（OS）方面是否存在益处。
方法和材料
在本研究中，大体积BM定义为直径≥4 cm（2 cm）。我们回顾了2005年至2013年期间来自2家机构的连续接受单纯单次分割SRS或术前或术后SRS联合手术治疗的患者记录。
结果
总体上，纳入了213例患者的223个接受治疗的大体积BM；66个BM（30%）仅接受SRS治疗，157个（70%）接受手术联合SRS治疗（63个术前联合，94个术后联合）。除了病变体积（中位数，5.9 cm对9.6 cm；P<0.001）、BM中位数（1.5对1，P = 0.002）、SRS中位数剂量（18 Gy对15 Gy，P<0.001）和既往全脑放疗（33%对5%，P<0.001）外，两组（SRS组与手术联合SRS组）平衡良好。手术联合SRS的局部复发（LR）率显著更低（1年LR率，36.7%对20.5%；P = 0.007）。切除状态对放射性坏死（RN）无差异，但术后SRS与术前SRS及单纯SRS相比，RN率显著增加（1年RN率，分别为22.6%对5%和12.3%；P<0.001）。手术联合SRS的OS显著更高（2年OS率，38.9%对19.8%；P = 0.01）。多变量调整分析和倾向评分匹配分析均显示了相似结果。
结论
在这项回顾性研究中，对于大体积BM患者，与单纯SRS相比，SRS联合全切除手术可使LR显著降低。术后SRS与最高的RN率相关。与单纯SRS相比，SRS联合手术切除可能改善大体积BM数量有限患者的预后。有必要进行进一步研究。
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