Rosenstock Tizian, Pöser Paul, Wasilewski David, Bauknecht Hans-Christian, Grittner Ulrike, Picht Thomas, Misch Martin, Onken Julia Sophie, Vajkoczy Peter
Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Digital Clinician Scientist Program, Berlin, Germany.
Front Oncol. 2022 May 16;12:873175. doi: 10.3389/fonc.2022.873175. eCollection 2022.
Recent studies demonstrated that gross total resection of brain metastases cannot always be achieved. Subtotal resection (STR) can result in an early recurrence and might affect patient survival. We initiated a prospective observational study to establish a MRI-based risk assessment for incomplete resection of brain metastases.
All patients in whom ≥1 brain metastasis was resected were prospectively included in this study (DRKS ID: DRKS00021224; Nov 2020 - Nov 2021). An interdisciplinary board of neurosurgeons and neuroradiologists evaluated the pre- and postoperative MRI (≤48h after surgery) for residual tumor. Extensive neuroradiological analyses were performed to identify risk factors for an unintended STR which were integrated into a regression tree analysis to determine the patients' individual risk for a STR.
We included 150 patients (74 female; mean age: 61 years), in whom 165 brain metastases were resected. A STR was detected in 32 cases (19.4%) (median residual tumor volume: 1.36ml, median EOR: 93.6%), of which 6 (3.6%) were intended STR (median residual tumor volume: 3.27ml, median EOR: 67.3%) - mainly due to motor-eloquent location - and 26 (15.8%) were unintended STR (uSTR) (median residual tumor volume: 0.64ml, median EOR: 94.7%). The following risk factors for an uSTR could be identified: subcortical metastasis ≥5mm distant from cortex, diffuse contrast agent enhancement, proximity to the ventricles, contact to falx/tentorium and non-transcortical approaches. Regression tree analysis revealed that the individual risk for an uSTR was mainly associated to the distance from the cortex (distance ≥5mm vs. <5mm: OR 8.0; 95%CI: 2.7 - 24.4) and the contrast agent patterns (diffuse vs. non-diffuse in those with distance ≥5mm: OR: 4.2; 95%CI: 1.3 - 13.7). The preoperative tumor volume was not substantially associated with the extent of resection.
Subcortical metastases ≥5mm distant from cortex with diffuse contrast agent enhancement showed the highest incidence of uSTR. The proposed MRI-based assessment allows estimation of the individual risk for uSTR and can help indicating intraoperative imaging.
近期研究表明，脑转移瘤的全切除并非总能实现。次全切除（STR）可能导致早期复发，并可能影响患者生存。我们开展了一项前瞻性观察性研究，以建立基于磁共振成像（MRI）的脑转移瘤不完全切除风险评估。
所有切除≥1个脑转移瘤的患者均前瞻性纳入本研究（德国临床试验注册编号：DRKS00021224；2020年11月 - 2021年11月）。由神经外科医生和神经放射科医生组成的跨学科委员会评估术前和术后MRI（术后≤48小时）以确定残留肿瘤。进行了广泛的神经放射学分析，以确定意外STR的风险因素，并将其纳入回归树分析，以确定患者发生STR的个体风险。
我们纳入了150例患者（74例女性；平均年龄：61岁），共切除165个脑转移瘤。32例（19.4%）检测到STR（中位残留肿瘤体积：1.36ml，中位切除范围：93.6%），其中6例（3.6%）为计划性STR（中位残留肿瘤体积：3.27ml，中位切除范围：67.3%），主要是由于位于运动功能区，26例（15.8%）为意外STR（uSTR）（中位残留肿瘤体积：0.64ml，中位切除范围：94.7%）。可确定以下uSTR的风险因素：距皮质≥5mm的皮质下转移瘤、弥漫性造影剂增强、靠近脑室、与大脑镰/小脑幕接触以及非经皮质入路。回归树分析显示，uSTR的个体风险主要与距皮质的距离（距离≥5mm与<5mm：比值比8.0；95%置信区间：2.7 - 24.4）和造影剂模式（距离≥5mm者中弥漫性与非弥漫性：比值比4.2；95%置信区间：1.3 - 13.7）有关。术前肿瘤体积与切除范围无显著相关性。
距皮质≥5mm且有弥漫性造影剂增强的皮质下转移瘤uSTR发生率最高。所提出的基于MRI的评估可估计uSTR的个体风险，并有助于指导术中成像。
