Department of Radiation Oncology, Northwestern Medicine Cancer Center and Proton Center, Warrenville, Illinois.
Division of Radiation Oncology, Department of Oncology, London Health Sciences Centre & Western University, London, Ontario, Canada.
Pract Radiat Oncol. 2022 Jul-Aug;12(4):265-282. doi: 10.1016/j.prro.2022.02.003. Epub 2022 May 6.
This guideline provides updated evidence-based recommendations addressing recent developments in the management of patients with brain metastases, including advanced radiation therapy techniques such as stereotactic radiosurgery (SRS) and hippocampal avoidance whole brain radiation therapy and the emergence of systemic therapies with central nervous system activity.
The American Society for Radiation Oncology convened a task force to address 4 key questions focused on the radiotherapeutic management of intact and resected brain metastases from nonhematologic solid tumors. The guideline is based on a systematic review provided by the Agency for Healthcare Research and Quality. Recommendations were created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength.
Strong recommendations are made for SRS for patients with limited brain metastases and Eastern Cooperative Oncology Group performance status 0 to 2. Multidisciplinary discussion with neurosurgery is conditionally recommended to consider surgical resection for all tumors causing mass effect and/or that are greater than 4 cm. For patients with symptomatic brain metastases, upfront local therapy is strongly recommended. For patients with asymptomatic brain metastases eligible for central nervous system-active systemic therapy, multidisciplinary and patient-centered decision-making to determine whether local therapy may be safely deferred is conditionally recommended. For patients with resected brain metastases, SRS is strongly recommended to improve local control. For patients with favorable prognosis and brain metastases receiving whole brain radiation therapy, hippocampal avoidance and memantine are strongly recommended. For patients with poor prognosis, early introduction of palliative care for symptom management and caregiver support are strongly recommended.
The task force has proposed recommendations to inform best clinical practices on the use of radiation therapy for brain metastases with strong emphasis on multidisciplinary care.
本指南提供了更新的循证建议，以应对脑转移瘤管理方面的最新进展，包括立体定向放射外科（SRS）和海马回避全脑放射治疗等先进的放射治疗技术，以及具有中枢神经系统活性的全身治疗方法的出现。
美国放射肿瘤学会召集了一个工作组，针对 4 个关键问题进行了讨论，这些问题集中在非血液系统实体瘤的完整和切除脑转移瘤的放射治疗管理上。本指南基于美国医疗保健研究与质量局提供的系统评价。建议是使用预先确定的共识制定方法和分级证据质量和推荐强度系统创建的。
强烈建议对脑转移瘤有限且东部合作肿瘤组表现状态为 0 到 2 的患者进行 SRS。有条件地建议与神经外科进行多学科讨论，以考虑对所有引起肿块效应和/或大于 4cm 的肿瘤进行手术切除。对于有症状的脑转移瘤患者，强烈建议进行局部治疗。对于有症状的脑转移瘤且有中枢神经系统活性全身治疗适应证的患者，强烈建议多学科和以患者为中心的决策，以确定局部治疗是否可以安全推迟。对于切除脑转移瘤的患者，强烈建议进行 SRS 以提高局部控制率。对于接受全脑放射治疗、海马回避和盐酸美金刚的预后良好的脑转移瘤患者，强烈建议使用。对于预后差的患者，强烈建议早期引入姑息治疗，以进行症状管理和照顾者支持。
工作组提出了建议，以告知脑转移瘤放射治疗的最佳临床实践，强烈强调多学科护理。
