多发脑转移瘤立体定向放射外科治疗的相关临床研究

发布时间：2018-03-17 12:42

  本文选题：脑转移瘤　切入点：磁共振成像　出处：《浙江大学》2016年博士论文　论文类型：学位论文

【摘要】：第一部分3D-BRAVO序列增强扫描在多发脑转移瘤诊断中的价值背景和目的脑转移瘤(BM)是颅内最常见的肿瘤之一,随着肿瘤系统治疗的改善,影像学检查方法的进步,脑转移瘤的检出率增加。其中大约一半以上的脑转移瘤患者为多发脑转移瘤。目前多发脑转移瘤的治疗方案包括全脑放疗(WBRT),立体定向放射外科治疗(SRS),手术,药物治疗等。准确诊断是否存在肿瘤脑转移、脑转移病灶的数目、大小及部位,对于脑转移患者的分级、治疗方案的选择、预后的评估都有着非常重要的价值。近年来,随着SRS治疗在多发脑转移瘤治疗中应用的越来越多,通过影像学检查精确的确定转移瘤病灶的数目和大小显得更为重要。目前临床上对于可疑脑转移瘤患者的常规检查是MR平扫和二维T1加权增强扫描,三维容积增强扫描应用相对较少。而三维颅脑容积磁共振成像(3D-BRAVO)序列采用薄层容积扫描,可明显减少漏诊、提高病灶检出率。本研究拟通过对比3D-BRAVO序列增强与常规2D-T1WI增强在诊断多发脑转移瘤病灶数目和大小的区别,探讨3D-BRAVO增强扫描在多发脑转移瘤诊断中的临床价值。方法筛选临床拟诊为BM患者45例行头颅MR平扫及增强检查,增强扫描序列包括2D-T1WI、3D-BRAVO两种,根据3D-BRAVO的图像为判断标准,对诊断为多发脑转移瘤的35例患者,分析两种不同增强扫描方式在显示的病灶数目,病灶大小上的区别。结果(1)病灶数目比较：在35例多发BM患者中,3D-BRAVO增强序列共发现175个病化,2D-T1WI增强序列共发现115个病灶(包括2个误诊病灶),以3D-BRAVO增强序列发现病灶个数为准,2D-T1WI增强发现病灶个数的灵敏度为64.57%,漏诊率为35.43%。(2)病灶大小比较：本组病例中,以2D-T1WI增强扫描方式中所发现的113个病灶为准,测量对应病灶在不同扫描方式中的大小,在2D-T1WI增强中所测病灶平均大小为12.06±9.29mm,3D-BRAVO增强中平均大小为12.96+9.75mm,利用配对资料的t检查,在两种扫描方式中所测病灶大小存在差异,3D-BRAVO增强序列所测病灶大小大于2D-T1WI增强。结论在多发脑转移瘤的诊断中,3D-BRAVO增强扫描比常规2D-T1WI增强更敏感,能更好地发现微小转移灶,可以成为脑转移瘤的常规扫描方式。第二部分238例多发脑转移瘤立体定向放射外科治疗的疗效和预后分析背景和目的脑转移瘤(BM)是指躯体其他部位的恶性肿瘤转移到颅内,大约20%40%的恶性肿瘤患者会出现脑转移。调查发现有超过一半以上的脑转移瘤患者为多发脑转移瘤。多发脑转移瘤一般进展迅速,预后差。多发脑转移瘤的治疗在脑转移的治疗中占有重要的地位。近年来立体定向放射外科(SRS)在颅内转移瘤治疗中的运用越来越多。但是对于多发脑转移瘤来说是否适合采取单独SRS治疗,有无必要联合WBRT治疗,以及WBRT治疗失败后行挽救性SRS治疗是否安全有效等还存在一定争议,有必要进行进一步研究总结。本研究拟通过对238例SRS治疗多发脑转移瘤的回顾性分析,探讨SRS治疗多发脑转移瘤的疗效以及影响预后的因素。方法回顾性分析我院2011年8月至2014年12月238例采用SRS治疗的多发脑转移瘤患者,其中SRS治疗组共191例,联合组22例,SRS挽救组25例。应用Kaplan-Meier计算生存时间,Log rank法进行单因素分析,Cox回归模型进行多因素分析研究各因素对预后的影响,p0.05为差异有统计学意义。结果238例患者随访中位时间13个月(2-54),3例失访,随访率为98.7%。全组伽玛刀治疗后6月局部控制率为88.3%。总的中位生存期为13个月。单纯SRS组、联合组、挽救组中位生存期分别为14、10、10个月(X2=6.818,P=0.033)。全组1年的生存率、2年生存率分别为53.9%,12.3%。单因素分析显示影响总生存率的预后因素有：治疗方式、颅外病变控制与否、KPS评分,RPA分级。多因素分析显示KPS评分、颅外病变控制与否影响生存,RPA分级是生存的独立预后因素。结论SRS对多发脑转移有较好疗效,单纯伽玛刀治疗和联合全脑放疗的生存无差异,多因素分析显示KPS评分,颅外疾病控制与否是影响患者生存期的独立的因素。而RPA分级、是生存的独立预后因素。第三部分单独伽玛刀立体定向放射外科治疗多发脑转移瘤的疗效分析目的评估单独采用伽玛刀放射外科治疗多发脑转移瘤的疗效及其影响因素。方法191例多发脑转移瘤病人单独接受伽玛刀放射外科治疗。平均脑转移瘤的个数为6.1个(2-26个),平均肿瘤总体积为58 cm3 (0.03～26.5cm3),平均边缘剂量为20.5 Gy,其中2-4个病灶组105例(55.0%),5～10个组54例(28.3%),≥11个组32例(16.7%)。结果191例患者随访中位时间14个月(4-54),全组患者伽玛刀治疗后6月肿瘤局部控制率为88.1%。总的中位生存期为14个月,2～4个组、5～10个组、≥11个组中位生存期分别为14月、13月和13个月(P=0.683),统计学无差异。全组1年的生存率、2年生存率分别为53.9%,12.3%。单因素和多因素分析显示影响总生存率的预后因素有：颅外病变控制与否、KPS评分,RPA分级。结论单独SRS对多发脑转移有较好疗效,2～4个病灶组,5-10个组,≥11个组的中位生存期无差别,治疗后颅内远处转移率及急慢性放疗副反应之间亦无差异,结合文献我们认为对于2～10病灶的多发脑转移瘤可以单独采用SRS治疗。多因素分析显示KPS评分,颅外疾病控制与否及RPA分级是影响患者生存的预后的因素。
[Abstract]:The first part of 3D-BRAVO sequence scan in multiple brain metastases background and objective brain metastases (BM) is one of the most common intracranial tumor, with the treatment of improving tumor system, imaging methods progress, increase the rate of detection of brain metastases. Of which about half of the patients with brain metastases for multiple brain metastases. The treatment of multiple brain metastases tumors including whole brain radiotherapy (WBRT), stereotactic radiosurgery (SRS), surgery, drug treatment. The existence of accurate diagnosis of brain metastasis, number of metastatic brain lesions, size and location, in patients with brain metastasis classification. The choice of treatment and prognosis assessment has a very important value. In recent years, with the increasing application of SRS in the treatment of metastatic tumor in the treatment of multiple brain metastases, number of lesions and confirmed by imaging precision The size is more important. The current clinical routine examination for suspected brain metastasis in patients with MR scan and T1 weighted scan two-dimensional, three-dimensional volume scan application is relatively small. And the 3D brain volume of magnetic resonance imaging (3D-BRAVO) sequence by scanning, can significantly reduce the misdiagnosis, improve the detection rate of lesions. This study intends to enhance and conventional enhanced 2D-T1WI in diagnosis of multiple brain metastases from the number and size of tumor by comparing the 3D-BRAVO sequence, to explore the clinical value of 3D-BRAVO scan in the diagnosis of metastatic tumors in multiple brain. Method of screening of clinically diagnosed BM patients 45 cases were examined by plain and enhanced MR scan enhanced scan sequence including 2D-T1WI, 3D-BRAVO two, according to the 3D-BRAVO image as the judgment standard, 35 cases of diagnosed multiple brain metastasis patients, analysis of two different ways in the enhanced scan of the lesion showed the number of The difference between the lesion size, number of lesions (1). The results of comparison: in 35 cases of multiple BM patients, enhanced 3D-BRAVO sequences were found in 175 patients, enhanced 2D-T1WI sequences were found in 115 lesions (including 2 misdiagnosed lesions), with the enhanced 3D-BRAVO sequence number of lesions were found to prevail, enhanced 2D-T1WI the sensitivity number of lesions was 64.57%, the misdiagnosis rate was 35.43%. (2): the size of the lesions in this group of cases, 113 lesions were found in 2D-T1WI enhancement scanning in the subject, measure the corresponding lesions in different scanning modes in size, in the 2D-T1WI enhancement of the measured mean lesion size was 12.06 + 9.29mm, 3D-BRAVO enhanced the average size of 12.96+9.75mm, using the paired t examination in two scanning modes in the lesion size differences, 3D-BRAVO enhanced sequence the lesion size is greater than 2D-T1WI. Conclusion the diagnosis of metastatic tumor enhancement in multiple brain In the 3D-BRAVO scan is more sensitive than conventional 2D-T1WI enhanced, can better detect micrometastasis can become a routine scanning of brain metastases. In the second part, 238 cases of multiple brain metastatic tumor treatment of stereotactic radiosurgery treatment results and prognostic analysis of background and objective brain metastases (BM) refers to other parts of the body malignant tumor metastasis to the intracranial malignant tumor patients about 20%40% develop brain metastases. The survey found that more than half of the patients with brain metastases for multiple brain metastases. Multiple brain metastasis and poor prognosis. The general progress rapidly, plays an important role in the treatment of brain metastasis in multiple brain metastasis therapy in recent years, stereotactic radiosurgery (SRS) in the treatment of intracranial metastatic tumor in the use of more and more. But it is suitable for tumor take SRS for multiple brain metastasis, there is no need to combined with WBRT treatment After the rescue SRS therapy is safe and effective, there is still a controversial failure and WBRT treatment, it is necessary to carry out further research. This study by retrospective analysis of 238 cases of SRS treatment of multiple brain metastases, SRS on treatment of multiple brain metastases and prognostic factors. Methods: a retrospective analysis in our hospital from August 2011 to December 2014, 238 cases of metastatic SRS treated multiple brain tumor patients, the SRS total of 191 cases of treatment group, combined group of 22 cases, 25 cases of SRS rescue group. Kaplan-Meier is used to calculate the survival time of single factor analysis and Log rank method, Cox regression model to analyze the effect of different factors on prognosis multi factor P0.05, the difference was statistically significant. The time of 13 months follow-up of 238 patients (2-54), 3 cases were lost, follow-up rate of 98.7%. group after gamma knife treatment in June, the local control rate was 88.3%. in the total students The storage period is 13 months. The pure SRS group, combination group, save the median survival time was 14,10,10 months (X2=6.818, P=0.033). The overall 1 year survival rate, 2 year survival rates were 53.9%, single factor 12.3%. analysis showed that the prognostic factors affecting overall survival rate: treatment. Extracranial lesions control or not, KPS score, RPA grade. Multivariate analysis showed that KPS score, extracranial lesions control and affect survival, RPA classification were independent prognostic factors. Conclusion SRS has a better therapeutic effect on multiple brain metastases, single gamma knife combined with whole brain radiotherapy treatment and survival had no significant difference. Multivariate analysis showed that KPS score, extracranial disease control is the independent influence factors for survival. The RPA classification was an independent prognostic factor for survival. Analysis and evaluation of curative effect of third mesh part alone stereotactic gamma knife radiosurgery for the treatment of multiple brain metastases alone. 鐢ㄤ冀鐜涘垁鏀惧皠澶栫�戞不鐤楀�氬彂鑴戣浆绉荤槫鐨勭枟鏁堝強鍏跺奖鍝嶅洜绱，

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