Lovo Eduardo E, Torres Leonel B, Campos Fidel J, Caceros Victor E, Barahona Kaory E, Minervini Mario H, Reyes William A
Radiosurgery, International Cancer Center, Diagnostic Hospital, San Salvador, SLV.
Nerosurgery, International Cancer Center, Diagnostic Hospital, San Salvador, SLV.
Cureus. 2019 Aug 24;11(8):e5472. doi: 10.7759/cureus.5472.
Introduction Surgery is considered the treatment of choice for patients with large, symptomatic brain metastases. This report describes a series of patients treated with upfront two-session radiosurgery rather than surgery for large brain metastases from breast and lung histology. Methods From October 2016 to January 2019, 10 consecutive patients with neurologic symptoms from large brain metastases producing mass effects underwent two sessions of radiosurgical treatments 30 days apart. The response was assessed by imaging and clinical evaluations. Results Ten patients had a total of 36 tumors; of these, 22 lesions with a mean volume of 12.3 ml (range, 7-78.4 ml) underwent two-session radiosurgery. The mean prescription dose for the first treatment was 13 Gy (range, 9-18 Gy) to the 50% isodose line, and the intratumoral mean dose was 17.9 Gy (12-22.9). All 10 patients had neurological symptoms, with a mean Karnofsky physical score (KPS) of 60 (range, 50-70) on the day of treatment. None of these patients required neurosurgical or emergency consultation related to worsening of neurological symptoms between the first and second treatments. At 30 days, the mean KPS was 80 and maintained at 80 at the last follow-up (range, 60-100; P=0.002), and mean lesion volume was 4.1 ml (range, 1.3-70 ml). The mean prescription dose for the second treatment was 12 Gy (range, 9-18 Gy) to the 50% isodose line, and the intratumoral mean dose was 17.9 Gy (11-22.4). The mean overall survival was 24 months (range, 3-32 months). At last follow-up, three patients (30%) had died, two of systemic progression and one of tumor progression, and at one year, local tumor control was 91% and 19 (86%) lesions showed documented local control at last follow up. In those tumors that progressed, the mean time to progression was eight months (range, 5-20 months), and the mean time to surgery was nine months (range, 5-32 months). Conclusion Two-session radiosurgery proved to be a safe treatment for patients with large, symptomatic metastases in this series. Neurological worsening after radiosurgery for large lesions of breast and lung histology may be an infrequent event. This strategy in radiosurgery may have neurological benefits for these patients providing adequate local tumor control while reducing the need of upfront surgery at diagnosis.
引言 手术被认为是有症状的大脑大转移瘤患者的首选治疗方法。本报告描述了一系列接受 upfront 两阶段放射外科治疗而非手术治疗的来自乳腺和肺组织学的大脑大转移瘤患者。方法 2016 年 10 月至 2019 年 1 月，10 例因大脑大转移瘤产生占位效应而出现神经症状的连续患者接受了间隔 30 天的两阶段放射外科治疗。通过影像学和临床评估来评估反应。结果 10 例患者共有 36 个肿瘤；其中，22 个平均体积为 12.3 ml（范围 7 - 78.4 ml）的病灶接受了两阶段放射外科治疗。第一次治疗的平均处方剂量为 50%等剂量线处 13 Gy（范围 9 - 18 Gy），瘤内平均剂量为 17.9 Gy（12 - 22.9）。所有 10 例患者均有神经症状，治疗当天的 Karnofsky 身体评分（KPS）平均为 60（范围 50 - 70）。这些患者中没有一人因第一次和第二次治疗之间神经症状恶化而需要神经外科会诊或急诊会诊。30 天时，平均 KPS 为 80，在最后一次随访时维持在 80（范围 60 - 100；P = 0.002），平均病灶体积为 4.1 ml（范围 1.3 - 70 ml）。第二次治疗的平均处方剂量为 50%等剂量线处 12 Gy（范围 9 - 18 Gy），瘤内平均剂量为 17.9 Gy（11 - 22.4）。平均总生存期为 24 个月（范围 3 - 32 个月）。在最后一次随访时，3 例患者（30%）死亡，2 例死于全身进展，1 例死于肿瘤进展，1 年时局部肿瘤控制率为 91%，19 个（86%）病灶在最后一次随访时有记录的局部控制。在进展的肿瘤中，平均进展时间为 8 个月（范围 5 - 20 个月），平均手术时间为 9 个月（范围 5 - 32 个月）。结论 在本系列中，两阶段放射外科治疗被证明是有症状的大脑大转移瘤患者的一种安全治疗方法。乳腺和肺组织学大病灶放射外科治疗后神经功能恶化可能是罕见事件。这种放射外科治疗策略可能对这些患者有神经功能益处，可提供充分的局部肿瘤控制，同时减少诊断时 upfront 手术的需求。
