Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 33, Seoul 05505, Republic of Korea.
Department of Pulmonology and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
AJR Am J Roentgenol. 2021 Nov;217(5):1184-1193. doi: 10.2214/AJR.21.25787. Epub 2021 May 26.
Although established guidelines give indications for performing staging brain MRI at initial diagnosis of non-small cell lung cancer (NSCLC), guidelines are lacking for performing surveillance brain MRI for patients without brain metastases at presentation. The purpose of this study is to estimate the cumulative incidence of and risk factors for brain metastasis development in patients with NSCLC without brain metastases at initial presentation. This retrospective study included 1495 patients with NSCLC (mean [± SD] age, 65 ± 10 years; 920 men and 575 women) without brain metastases at initial evaluation that included brain MRI. Follow-up brain MRI was ordered at the discretion of the referring physicians. MRI examinations were reviewed in combination with clinical records for brain metastasis development; patients not undergoing MRI were deemed to have not had metastases develop through last clinical follow-up. The cumulative incidence of brain metastases was determined, with death considered a competing risk, and was stratified by clinical stage group, cell type, and epidermal growth factor receptor () gene mutation status. Univariable and multivariable Cox proportional hazards regression analyses were performed. A total of 258 of 1495 patients (17.3%) underwent follow-up brain MRI, and 72 (4.8%) had brain metastases develop at a median of 12.3 months after initial diagnosis of NSCLC. Of the 72 patients who had metastases develop, 44.4% had no neurologic symptoms, and 58.3% had stable primary thoracic disease. The cumulative incidence of brain metastases at 6, 12, 18, and 24 months after initial evaluation was 0.6%, 2.1%, 4.2%, and 6.8%, respectively. Cumulative incidence at 6, 12, 18, and 24 months was higher ( < .001) in patients with clinical stage III-IV disease (1.3%, 3.9%, 7.7%, and 10.9%, respectively) than in those with clinical stage I-II disease (0.0%, 0.8%, 1.2%, and 2.6%, respectively), and it was higher ( < .001) in patients with mutation-positive adenocarcinoma (0.7%, 2.5%, 6.3%, and 12.3%, respectively) than in those with mutation-negative adenocarcinoma (0.4%, 1.8%, 2.9%, and 4.4%, respectively). Among 1109 patients with adenocarcinoma, independent risk factors for the development of brain metastasis were clinical stage III-IV (hazard ratio [HR], 9.39; < .001) and mutation-positive status (HR, 1.78; = .04). The incidence of brain metastasis over the study interval was 8.7% among patients with clinical stage III-IV disease and 17.4% among those with mutation-positive adenocarcinoma. Clinical stage III-IV and mutation-positive adenocarcinoma are independent risk factors for brain metastasis development. For patients with clinical stage III-IV disease or mutation-positive adenocarcinoma, surveillance brain MRI performed 12 months after initial evaluation may be warranted.
虽然已有明确的指南为非小细胞肺癌（NSCLC）初始诊断时进行脑 MRI 分期提供了指导，但对于无脑转移初始表现的患者进行脑转移监测 MRI 却缺乏相应的指南。本研究旨在评估无初始脑转移的 NSCLC 患者中脑转移发展的累积发生率和危险因素。本回顾性研究纳入了 1495 例无初始评估脑 MRI 脑转移的 NSCLC 患者（平均[±标准差]年龄为 65±10 岁；920 例男性和 575 例女性）。根据医生的判断进行了后续脑 MRI 检查。将 MRI 检查结果与临床记录相结合，以确定是否有脑转移；未进行 MRI 检查的患者被认为无转移发生，直到最后一次临床随访。通过竞争风险确定脑转移的累积发生率，并按临床分期、细胞类型和表皮生长因子受体（）基因突变状态进行分层。进行了单变量和多变量 Cox 比例风险回归分析。共有 1495 例患者中的 258 例（17.3%）接受了随访脑 MRI，其中 72 例（4.8%）在 NSCLC 初始诊断后 12.3 个月时出现脑转移。在发生转移的 72 例患者中，44.4%没有神经系统症状，58.3%的患者原发胸部疾病稳定。初始评估后 6、12、18 和 24 个月时脑转移的累积发生率分别为 0.6%、2.1%、4.2%和 6.8%。6、12、18 和 24 个月时的累积发生率在临床分期为 III-IV 期的患者中更高（<0.001），分别为 1.3%、3.9%、7.7%和 10.9%，而在临床分期为 I-II 期的患者中则较低（<0.001），分别为 0.0%、0.8%、1.2%和 2.6%；在突变阳性的腺癌患者中更高（<0.001），分别为 0.7%、2.5%、6.3%和 12.3%，而在突变阴性的腺癌患者中则较低（<0.001），分别为 0.4%、1.8%、2.9%和 4.4%。在 1109 例腺癌患者中，脑转移发展的独立危险因素是临床分期为 III-IV 期（危险比[HR]，9.39；<0.001）和突变阳性状态（HR，1.78；=0.04）。在研究期间，临床分期为 III-IV 期的患者中有 8.7%发生脑转移，而突变阳性的腺癌患者中有 17.4%发生脑转移。临床分期 III-IV 期和突变阳性的腺癌是脑转移发展的独立危险因素。对于临床分期为 III-IV 期或突变阳性的腺癌患者，初始评估后 12 个月进行脑转移监测 MRI 可能是合理的。
