Association of Neurosurgical Resection With Development of Pachymeningeal Seeding in Patients With Brain Metastases
Association of Neurosurgical Resection With Development of Pachymeningeal Seeding in Patients With Brain Metastases
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DOI：
10.1001/jamaoncol.2018.7204
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发表时间：
2019-05-01
期刊：
影响因子：
28.4
通讯作者：
Aizer, Ayal A.
中科院分区：
文献类型：
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作者：
Cagney, Daniel N.;Lamba, Nayan;Aizer, Ayal A.
重要性神经外科切除术是一个重要的管理策略，为患者的大，症状性脑转移瘤，并越来越多地其次是立体定向放射治疗，而不是全脑放射。神经外科切除术是否与肿瘤扩散超出切除部位和辅助立体定向放射野有关仍不清楚。目的描述脑转移瘤患者接受辅助立体定向放射治疗时硬脑膜种植与神经外科切除术的相关性和发生率。设置.和参与者回顾性队列研究，对2001年至2015年期间接受神经外科切除术和立体定向放射治疗（n = 318）与单纯放射治疗（n = 870）的新诊断脑转移瘤患者进行连续样本分析。（硬脑膜和/或外蛛网膜）和le[接受神经外科切除术和立体定向放射治疗与单纯放射治疗的患者中的脑膜疾病，以及与在接受神经外科切除术后进行立体定向放射治疗的患者中进行硬脑膜种植。结果在1188例新诊断的脑转移瘤患者中，133例男性和185例女性（平均[SD]年龄，58.9 [11.5]岁）接受了神经外科切除术。切除术与硬脑膜种植有关（318例患者中的36例与870例患者中的0例; P <0.001），但与软脑膜疾病无关（风险比[HR]，1.14; 95%CI，0.73-1.77; P = 0.56）。总共有36/428例（8.4%）手术并发硬脑膜种植，切除既往放疗转移瘤的发生率高于未放疗转移瘤（HR，2.39; 95% CI，1.25-4.57; P = 0.008）。硬脑膜种植患者随后发生新发脑转移和软脑膜疾病的发生率相对较低（分别为8/51 [16%]和6/48 [13%]）。在硬脑膜种植的患者中，主要由于进行性硬脑膜疾病导致的神经系统死亡占36例死亡中的26例（72%），但当采用挽救性放射治疗时，49.1%的患者存活1年或更长时间。在立体定向放射野之外的硬脑膜接种代表了通常证明难以挽救的显著肿瘤学事件。然而，在一些患者中，可以通过放射治疗方法实现疾病控制。
IMPORTANCE Neurosurgical resection represents an important management strategy for patients with large, symptomatic brain metastases and increasingly is followed by stereotactic radiation as opposed to whole-brain radiation. Whether neurosurgical resection is associated with tumor spread beyond the resection site and adjuvant stereotactic radiation field remains unknown.OBJECTIVE To characterize the associat on and incidence of pachymeningeal seeding with neurosurgical resection in patients with brain metastases treated with adjuvant stereotactic radiation.DESIGN. SETTING. AND PARTICIPANTS Retrospective cohort study of a consecutive sample of patients with newly diagnosed brain metastases managed with neurosurgical resection and stereotactic radiation (n = 318) vs radiation alone (n = 870) between 2001and 2015.MAIN OUTCOMES AND MEASURES Incidence of pachymeningeal seeding (dural and/or outer arachnoid) and le[tomeningeal disease in patients treated with neurosurgical resection and stereotactic radiation vs radiation alone and the risk factors and outcomes associated with pachymeningeal seeding in patients treated with neurosurgical resection followed by stereotactic radiation. RESULTS In 1188 patients with newly diagnosed brain metastases, 133 men and 185 women (mean [SD] age, 58.9 [11.5] years) underwent neurosurgical resection. Resection was found to be associated with pachymeningeal seeding (36 of 318 patients vs 0 of 870 patients; P`.001) but not leptomeningeal disease (hazard ratio [HR], 1.14; 95% CI, 0.73-1.77; P =.56). In total, 36 (8.4%) of 428 operations were complicated by pachymeningeal seeding, with a higher incidence noted with resection of previously irradiated vs unirradiated metastases (HR, 2.39; 95% CI, 1.25-4.57; P =.008). Patients with pachymeningeal seeding had relatively low rates of subsequent development of new brain metastases and leptomeningeal disease (8 [16%] of 51and 6 [13%] of 48, respectively). Among patients with pachymeningeal seeding, neurologic death primarily owing to progressive pachymeningeal disease accounted for 26 (72%) of 36 deaths, but when treated with salvage radiation, 49.1% of patients survived lyear or longer.CONCLUSIONS AND RELEVANCE In the era of omission of adjuvant whole-brain radiation after neurosurgical resection, pachymeningeal seeding beyond the stereotactic radiation field represents a notable oncologic event that often proves difficult to salvage. However, in some patients, disease control can be achieved with radiotherapeutic approaches.