Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es): An American Society for Radiation Oncology evidence-based guideline.
Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es): An American Society for Radiation Oncology evidence-based guideline.
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DOI：
10.1016/j.prro.2011.12.004
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发表时间：
2012-07
影响因子：
3.3
通讯作者：
Chang, Eric L
中科院分区：
文献类型：
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作者：
Tsao, May N;Rades, Dirk;Wirth, Andrew;Lo, Simon S;Danielson, Brita L;Gaspar, Laurie E;Sperduto, Paul W;Vogelbaum, Michael A;Radawski, Jeffrey D;Wang, Jian Z;Gillin, Michael T;Mohideen, Najeeb;Hahn, Carol A;Chang, Eric L
系统地回顾新诊断的脑实质内转移患者的放射治疗和手术治疗的证据。确定了本循证指南中要解决的关键临床问题。系统地检索和审查了全面发表的涉及新诊断的脑实质内转移瘤治疗的随机对照试验。美国预防服务工作组的证据级别用于对各种管理方案进行分类。新诊断的单发或多发脑转移患者的治疗选择取决于估计的预后和治疗目的（生存、局部治疗病灶控制、远端脑控制、神经认知保留）。单发脑转移瘤预后良好（预期生存3个月或以上）：对于大于3至4厘米且适合安全完全切除的单发脑转移瘤，应考虑全脑放疗（WBRT）和手术（1级）。另一种选择是对切除腔进行手术和放射外科/放射增强治疗（3 级）。对于小于3至4厘米的单发转移灶，应考虑单独放射外科治疗或全脑放疗加放射外科治疗或全脑放疗加手术（均基于1级证据）。另一种选择是手术和放射外科手术或对切除腔进行增强放射治疗（3 级）。对于不可切除或切除不完全的单个脑转移瘤（小于3至4厘米），应考虑全脑放疗和放射外科治疗，或单独放射外科治疗（1级）。对于不可切除的单发脑转移瘤（大于3至4厘米），应考虑WBRT（3级）。多发性脑转移瘤和良好的预后（预期生存期3个月或以上）：对于选定的多发性脑转移瘤（全部小于3至4厘米）的患者，基于1级证据，应考虑单独放射外科手术、全脑放疗加放射外科手术或单独全脑放疗。也可以考虑安全切除脑转移瘤或引起显着占位效应的转移瘤和术后全脑放疗（WBRT）（3级）。预后不良的患者（预计生存期少于3个月）：预后不良的单发或多发脑转移患者应考虑接受姑息治疗，联合或不联合WBRT（3级）。然而，应该认识到，医生准确预测患者生存率的能力是有限的。诸如递归分区分析和诊断特定的分级预后评估之类的预后系统可能会有所帮助。放射治疗干预（WBRT 或放射外科）与改善大脑控制有关。在选定的单发脑转移患者中，放射外科或手术已被发现可以提高生存率和局部治疗转移控制（与单独 WBRT 相比）。
To systematically review the evidence for the radiotherapeutic and surgical management of patients newly diagnosed with intraparenchymal brain metastases. Key clinical questions to be addressed in this evidence-based Guideline were identified. Fully published randomized controlled trials dealing with the management of newly diagnosed intraparenchymal brain metastases were searched systematically and reviewed. The U.S. Preventative Services Task Force levels of evidence were used to classify various options of management. The choice of management in patients with newly diagnosed single or multiple brain metastases depends on estimated prognosis and the aims of treatment (survival, local treated lesion control, distant brain control, neurocognitive preservation). Single brain metastasis and good prognosis (expected survival 3 months or more): For a single brain metastasis larger than 3 to 4 cm and amenable to safe complete resection, whole brain radiotherapy (WBRT) and surgery (level 1) should be considered. Another alternative is surgery and radiosurgery/radiation boost to the resection cavity (level 3). For single metastasis less than 3 to 4 cm, radiosurgery alone or WBRT and radiosurgery or WBRT and surgery (all based on level 1 evidence) should be considered. Another alternative is surgery and radiosurgery or radiation boost to the resection cavity (level 3). For single brain metastasis (less than 3 to 4 cm) that is not resectable or incompletely resected, WBRT and radiosurgery, or radiosurgery alone should be considered (level 1). For nonresectable single brain metastasis (larger than 3 to 4 cm), WBRT should be considered (level 3). Multiple brain metastases and good prognosis (expected survival 3 months or more): For selected patients with multiple brain metastases (all less than 3 to 4 cm), radiosurgery alone, WBRT and radiosurgery, or WBRT alone should be considered, based on level 1 evidence. Safe resection of a brain metastasis or metastases causing significant mass effect and postoperative WBRT may also be considered (level 3). Patients with poor prognosis (expected survival less than 3 months): Patients with either single or multiple brain metastases with poor prognosis should be considered for palliative care with or without WBRT (level 3). It should be recognized, however, that there are limitations in the ability of physicians to accurately predict patient survival. Prognostic systems such as recursive partitioning analysis, and diagnosis-specific graded prognostic assessment may be helpful. Radiotherapeutic intervention (WBRT or radiosurgery) is associated with improved brain control. In selected patients with single brain metastasis, radiosurgery or surgery has been found to improve survival and locally treated metastasis control (compared with WBRT alone).