Guberina Nika, Padeberg Florian, Pöttgen Christoph, Guberina Maja, Lazaridis Lazaros, Jabbarli Ramazan, Deuschl Cornelius, Herrmann Ken, Blau Tobias, Wrede Karsten H, Keyvani Kathy, Scheffler Björn, Hense Jörg, Layer Julian P, Glas Martin, Sure Ulrich, Stuschke Martin
Department of Radiation Therapy, West German Cancer Center, University of Duisburg-Essen, University Hospital Essen, 45147 Essen, Germany.
Department of Neurology, University of Duisburg-Essen, University Hospital Essen, 45147 Essen, Germany.
Cancers (Basel). 2023 May 30;15(11):2982. doi: 10.3390/cancers15112982.
While prognosis of glioblastoma after trimodality treatment is well examined, recurrence pattern with respect to the delivered dose distribution is less well described. Therefore, here we examine the gain of additional margins around the resection cavity and gross-residual-tumor.
All recurrent glioblastomas initially treated with radiochemotherapy after neurosurgery were included. The percentage overlap of the recurrence with the gross tumor volume (GTV) expanded by varying margins (10 mm to 20 mm) and with the 95% and 90% isodose was measured. Competing-risks analysis was performed in dependence on recurrence pattern.
Expanding the margins from 10 mm to 15 mm, to 20 mm, to the 95%- and 90% isodose of the delivered dose distribution with a median margin of 27 mm did moderately increase the proportion of relative in-field recurrence volume from 64% to 68%, 70%, 88% and 88% ( < 0.0001). Overall survival of patients with in-and out-field recurrence was similar ( = 0.7053). The only prognostic factor significantly associated with out-field recurrence was multifocality of recurrence ( = 0.0037). Cumulative incidences of in-field recurrences at 24 months were 60%, 22% and 11% for recurrences located within a 10 mm margin, outside a 10 mm margin but within the 95% isodose, or outside the 95% isodose ( < 0.0001). Survival from recurrence was improved after complete resection ( = 0.0069). Integrating these data into a concurrent-risk model shows that extending margins beyond 10 mm has only small effects on survival hardly detectable by clinical trials.
Two-thirds of recurrences were observed within a 10 mm margin around the GTV. Smaller margins reduce normal brain radiation exposure allowing for more extensive salvage radiation therapy options in case of recurrence. Prospective trials using margins smaller than 20 mm around the GTV are warranted.
虽然胶质母细胞瘤三联疗法后的预后已得到充分研究，但关于所给予剂量分布的复发模式描述较少。因此，我们在此研究切除腔和大体残留肿瘤周围额外边缘的获益情况。
纳入所有最初在神经外科手术后接受放化疗治疗的复发性胶质母细胞瘤患者。测量复发灶与扩大不同边缘（10毫米至20毫米）后的大体肿瘤体积（GTV）以及95%和90%等剂量线的重叠百分比。根据复发模式进行竞争风险分析。
将边缘从10毫米扩大到15毫米、20毫米、至所给予剂量分布的95%和90%等剂量线（中位边缘为27毫米），确实适度增加了相对野内复发体积的比例，从64%增至68%、70%、88%和88%（P<0.0001）。野内和野外复发患者的总生存期相似（P = 0.7053）。与野外复发显著相关的唯一预后因素是复发的多灶性（P = 0.0037）。对于位于10毫米边缘内、10毫米边缘外但在95%等剂量线内或95%等剂量线外的复发，24个月时野内复发的累积发生率分别为60%、22%和11%（P<0.0001）。完全切除后复发后的生存期有所改善（P = 0.0069）。将这些数据整合到一个竞争风险模型中显示，将边缘扩大超过10毫米对生存期的影响很小，临床试验几乎难以检测到。
三分之二的复发发生在GTV周围10毫米的边缘内。较小的边缘可减少正常脑区的辐射暴露，以便在复发时提供更广泛的挽救性放疗选择。有必要进行前瞻性试验，使用GTV周围小于20毫米的边缘。
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