Levine Cancer Institute, Atrium Health, Charlotte, North Carolina.
Southeast Radiation Oncology Group, Charlotte, North Carolina.
JAMA Oncol. 2023 Aug 1;9(8):1066-1073. doi: 10.1001/jamaoncol.2023.1629.
Preoperative stereotactic radiosurgery (SRS) has been demonstrated as a feasible alternative to postoperative SRS for resectable brain metastases (BMs) with potential benefits in adverse radiation effects (AREs) and meningeal disease (MD). However, mature large-cohort multicenter data are lacking.
To evaluate preoperative SRS outcomes and prognostic factors from a large international multicenter cohort (Preoperative Radiosurgery for Brain Metastases-PROPS-BM).
DESIGN, SETTING, AND PARTICIPANTS: This multicenter cohort study included patients with BMs from solid cancers, of which at least 1 lesion received preoperative SRS and a planned resection, from 8 institutions. Radiosurgery to synchronous intact BMs was allowed. Exclusion criteria included prior or planned whole-brain radiotherapy and no cranial imaging follow-up. Patients were treated between 2005 and 2021, with most treated between 2017 and 2021.
Preoperative SRS to a median dose to 15 Gy in 1 fraction or 24 Gy in 3 fractions delivered at a median (IQR) of 2 (1-4) days before resection.
The primary end points were cavity local recurrence (LR), MD, ARE, overall survival (OS), and multivariable analysis of prognostic factors associated with these outcomes.
The study cohort included 404 patients (214 women [53%]; median [IQR] age, 60.6 [54.0-69.6] years) with 416 resected index lesions. The 2-year cavity LR rate was 13.7%. Systemic disease status, extent of resection, SRS fractionation, type of surgery (piecemeal vs en bloc), and primary tumor type were associated with cavity LR risk. The 2-year MD rate was 5.8%, with extent of resection, primary tumor type, and posterior fossa location being associated with MD risk. The 2-year any-grade ARE rate was 7.4%, with target margin expansion greater than 1 mm and melanoma primary being associated with ARE risk. Median OS was 17.2 months (95% CI, 14.1-21.3 months), with systemic disease status, extent of resection, and primary tumor type being the strongest prognostic factors associated with OS.
In this cohort study, the rates of cavity LR, ARE, and MD after preoperative SRS were found to be notably low. Several tumor and treatment factors were identified that are associated with risk of cavity LR, ARE, MD, and OS after treatment with preoperative SRS. A phase 3 randomized clinical trial of preoperative vs postoperative SRS (NRG BN012) has began enrolling (NCT05438212).
术前立体定向放射外科 (SRS) 已被证明是可切除脑转移瘤 (BM) 术后 SRS 的可行替代方法，具有潜在的不良反应 (AREs) 和脑膜疾病 (MD) 优势。然而，缺乏成熟的大型队列多中心数据。
评估来自大型国际多中心队列（术前放射外科治疗脑转移瘤-PROPS-BM）的术前 SRS 结果和预后因素。
设计、地点和参与者：这项多中心队列研究纳入了来自实体瘤的 BM 患者，其中至少有 1 个病灶接受了术前 SRS 和计划切除，来自 8 个机构。允许对同步完整的 BM 进行放射外科治疗。排除标准包括之前或计划进行全脑放疗和无颅成像随访。患者在 2005 年至 2021 年之间接受治疗，其中大多数在 2017 年至 2021 年之间接受治疗。
术前 SRS 中位剂量为 15 Gy 单次分割或 24 Gy 3 次分割，在切除前中位（IQR）2（1-4）天给予。
主要终点是腔隙局部复发（LR）、MD、ARE、总生存（OS），以及与这些结果相关的多变量分析的预后因素。
研究队列包括 404 名患者（214 名女性[53%]；中位[IQR]年龄为 60.6[54.0-69.6]岁），共切除了 416 个索引病灶。2 年腔隙 LR 率为 13.7%。全身疾病状态、切除范围、SRS 分割、手术类型（分片与整块）和原发肿瘤类型与腔隙 LR 风险相关。2 年 MD 率为 5.8%，切除范围、原发肿瘤类型和后颅窝位置与 MD 风险相关。2 年任何级别 ARE 率为 7.4%，靶区边缘扩张大于 1mm 和黑色素瘤原发病与 ARE 风险相关。中位 OS 为 17.2 个月（95%CI，14.1-21.3 个月），全身疾病状态、切除范围和原发肿瘤类型是与 OS 相关的最强预后因素。
在这项队列研究中，术前 SRS 后腔隙 LR、ARE 和 MD 的发生率明显较低。发现几个肿瘤和治疗因素与术前 SRS 治疗后腔隙 LR、ARE、MD 和 OS 的风险相关。一项关于术前与术后 SRS 的 III 期随机临床试验（NRG BN012）已开始招募（NCT05438212）。
