McKay Michael Jerome
Northern Cancer Service, North West Cancer Centre, Burnie, Tasmania, Australia.
The University of Tasmania, Rural Clinical School, Northwest Regional Hospital, Burnie, Tasmania, Australia.
Ann Transl Med. 2021 Nov;9(21):1629. doi: 10.21037/atm-21-3665.
To broadly review the modern management of brain metastases.
Brain metastases are the commonest neurological manifestation of cancer and a major cause of morbidity in cancer patients. Brain metastases are increasing in frequency, as a result of longer life expectancy of cancer patients, more sensitive methods for brain metastasis detection and an ageing population. The proportional incidence of brain metastases according to cancer of origin, from greatest to least, is lung cancer, melanoma, renal, breast and colorectal cancers. Patients with lung cancer and melanoma are most likely to have brain metastases at diagnosis. Brain metastases cause a variety of symptoms, depending on their size and location, whether they cause mass effect and oedema, compression of the brain parenchyma, or focal neurological deficits. The major differential diagnoses of brain metastases include primary tumours and vascular/inflammatory lesions. Prognosis is dependent on the site, number and volume of lesions, the patients' performance status, age and the activity and extent of extracranial disease.
English literature articles in PubMed from 1950 to June 2021 were reviewed. Article bibliographies provided further references.
Treatment of brain metastasis patients has moved from considering them as a homogenous population of patients, to individualised treatment. In those brain metastases patients of satisfactory performance status with a solitary lesion, especially one in a non-eloquent/accessible area causing significant mass effect and/or raised intracranial pressure or for whom the diagnosis is in doubt (histology needed), surgical resection is usually the treatment of choice. For multiple brain metastases, radiotherapy with or without systemic therapies are usually employed. For relatively fit patients with limited numbers of brain metastases (e.g., 4 or less), stereotactic radiosurgery is standard of care. Current clinical trials are testing the efficacy of stereotactic treatment alone for >4 brain metastases (although it is increasingly used for such patients in many centres) as well as integration of local therapies with targeted and immunological therapies in appropriately selected cases. In certain circumstances, cranial irradiation can be omitted.
全面综述脑转移瘤的现代管理。
脑转移瘤是癌症最常见的神经系统表现，也是癌症患者发病的主要原因。由于癌症患者预期寿命延长、脑转移瘤检测方法更灵敏以及人口老龄化，脑转移瘤的发生率正在上升。根据原发癌的不同，脑转移瘤的比例发病率从高到低依次为肺癌、黑色素瘤、肾癌、乳腺癌和结直肠癌。肺癌和黑色素瘤患者在诊断时最有可能发生脑转移瘤。脑转移瘤会引起多种症状，这取决于其大小和位置，以及是否会导致占位效应和水肿、压迫脑实质或引起局灶性神经功能缺损。脑转移瘤的主要鉴别诊断包括原发性肿瘤和血管/炎性病变。预后取决于病变的部位、数量和体积、患者的身体状况、年龄以及颅外疾病的活动情况和范围。
回顾了1950年至2021年6月PubMed上的英文文献文章。文章参考文献提供了更多参考资料。
脑转移瘤患者的治疗已从将他们视为同质化患者群体，转变为个体化治疗。对于那些身体状况良好、有单个病灶的脑转移瘤患者，尤其是位于非功能区/可接近区域、引起明显占位效应和/或颅内压升高的病灶，或者诊断存疑（需要组织学检查）的患者，手术切除通常是首选治疗方法。对于多发脑转移瘤，通常采用放疗联合或不联合全身治疗。对于脑转移瘤数量有限（例如4个或更少）的相对健康患者，立体定向放射外科是标准治疗方法。目前的临床试验正在测试单独立体定向治疗对>4个脑转移瘤的疗效（尽管在许多中心越来越多地用于此类患者），以及在适当选择的病例中将局部治疗与靶向治疗和免疫治疗相结合的疗效。在某些情况下，可以省略颅脑照射。
