Armstrong J G, Wronski M, Galicich J, Arbit E, Leibel S A, Burt M
Department of Radiation Oncology and Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY.
J Clin Oncol. 1994 Nov;12(11):2340-4. doi: 10.1200/JCO.1994.12.11.2340.
Although resection of single brain metastases and postoperative whole-brain radiation therapy (WBRT) improves survival, compared with treatment using WBRT alone, the value of postoperative WBRT after resection of brain metastases is controversial. We analyzed the largest reported series of lung cancer patients with resected brain metastases to evaluate the impact of postoperative WBRT.
Between 1974 and 1989, 185 patients with non-small-cell lung cancer (NSCLC) underwent resection of brain metastases. Patients who had received preoperative WBRT (23%, 42 of 185) were excluded. The remaining patients were divided into group A (no WBRT; n = 32), group B (patients received WBRT and were prognostically matched to group A; n = 32), and group C (all other WBRT patients; n = 79). Most patients received postoperative doses of 30 Gy in 10 fractions. Higher doses were used in 16% of group B and 18% of group C patients.
Overall 5-year survival rates were as follows: group A, 12%; B, 8%; C, 16%. Overall brain failures occurred in 38% of patients in group A, 47% in group B, and 42% in group C. The use of WBRT (group A v groups B plus C) had no apparent impact on survival or on overall brain failure rates. In particular, no improvement in either of these parameters could be demonstrated when group B was compared with group A. Focal failure (defined as failure within the brain adjacent to the site of the resected brain metastases) occurred as follows: group A, 34% (11 of 32); groups B plus C, 23% (25 of 111) (P = .07). WBRT significantly reduced focal failure for patients with adenocarcinoma (group A, 33% [eight of 24]; groups B plus C, 14% [11 of 79]; P = .05). Nonfocal failure (anatomically distinct from the resected metastasis) occurred in 9% of patients in group A (three of 32), 21% in groups B plus C (23 of 111) (P = .07).
Long-term survival is possible when NSCLC brain metastases are resected. Postoperative WBRT as used in this series only had an impact on the focal control of brain metastases and this effect was of borderline significance. The lack of conclusive benefit supports the need for ongoing randomized trials to test the value of adjuvant postoperative WBRT. Brain failures were relatively common in all three groups of patients, which suggests that doses greater than 30 Gy need to be studied.
尽管切除单个脑转移瘤并术后行全脑放疗（WBRT）可提高生存率，但与单纯使用WBRT治疗相比，脑转移瘤切除术后行WBRT的价值仍存在争议。我们分析了已报道的最大系列的接受脑转移瘤切除术的肺癌患者，以评估术后WBRT的影响。
1974年至1989年间，185例非小细胞肺癌（NSCLC）患者接受了脑转移瘤切除术。排除术前接受过WBRT的患者（23%，185例中的42例）。其余患者分为A组（未接受WBRT；n = 32）、B组（接受WBRT且预后与A组匹配；n = 32）和C组（所有其他接受WBRT的患者；n = 79）。大多数患者术后接受10次分割共30 Gy的剂量。B组16%和C组18%的患者使用了更高的剂量。
总体5年生存率如下：A组为12%；B组为8%；C组为16%。总体脑转移复发率在A组患者中为38%，B组为47%，C组为42%。使用WBRT（A组与B组加C组相比）对生存率或总体脑转移复发率无明显影响。特别是，将B组与A组比较时，这两个参数均未显示出改善。局灶性复发（定义为切除的脑转移瘤部位附近脑内的复发）情况如下：A组为34%（32例中的11例）；B组加C组为23%（111例中的25例）（P = 0.07）。WBRT显著降低了腺癌患者的局灶性复发（A组为33% [24例中的8例]；B组加C组为14% [79例中的11例]；P = 0.05）。非局灶性复发（在解剖学上与切除的转移瘤不同）在A组患者中为9%（32例中的3例），在B组加C组中为21%（111例中的23例）（P = 0.07）。
NSCLC脑转移瘤切除术后有可能实现长期生存。本系列中使用的术后WBRT仅对脑转移瘤的局灶性控制有影响，且这种影响具有临界意义。缺乏确凿的益处支持需要进行持续的随机试验来检验辅助性术后WBRT的价值。脑转移复发在所有三组患者中都相对常见，这表明需要研究大于30 Gy的剂量。
