江浩—安徽—肺癌脑转移的治疗

1、肺癌脑转移的治疗进展 一石激起千重浪？Mulvenna P,et al. Lancet. 2016 Oct 22;388(10055):2004-2014. WBRT for NSCLC：Yes & No？Mulvenna P,et al. Lancet. 2016 Oct 22;388(10055):2004-2014. 本研究的一般描述 a non-inferiority, phase 3 randomised trial done at 69 UK and three Australian centres. NSCLC patients with brain metastases

2、 unsuitable for surgical resection or stereotactic radiotherapy optimal supportive care (OSC) including dexamethasone plus WBRT (20 Gy in five daily fractions) or OSC alone including dexamethasone The primary outcome measure：quality-adjusted life-years (QALYs). QALYs were generated from overall surv

3、ival and patients weekly completion of the EQ-5D questionnaire. Between March 2, 2007, and Aug 29, 2014, 538 patients were recruited from 69 UK and three Australian centres, and were randomly assigned to receive either OSC plus WBRT (269) or OSC alone (269).Interpretation Although the primary outcom

4、e measure result includes the prespecified non-inferiority margin, the combination of the small difference in QALYs and the absence of a difference in survival and quality of life between the two groups suggests that WBRT provides little additional clinically significant benefit for this patient gro

5、up.Overall SurvivalAverage Quality of LifeAverage QALYForest Plot of SurvivalIn summary QUARTZ provides compelling information for clinicians and patients alike; for younger patients, WBRT might offer a survival advantage but for all other groups, omitting WBRT does not significantly affect QALY or

6、overall survival.Nov. 2016：WBRT for NSCLC the end of an era?Anna M.E.B, et al. J Thorac. Dis. 2016;8(11):E1525-E1527RTOG-RPA: Class 1-3 A three-class recursive partitioning (RPA) system by the RTOG to describe different prognostic groups of patients with brain metastases. RPA Class I: the most favor

7、able prognostic group, KPS70, an age 65 years and controlled primary tumor without extracranial metastases. RPA Class III :the poorest prognosis patients, KPS 70. RPA Class II:The remainders of patientsGaspar LE, et al. Int J Radiat Oncol Biol Phys.2000;47:1001-6.How to choose？ Quartz trial is groun

8、dbreaking in that it is the first prospective randomized study providing evidence that poor prognosis patients with brain metastases from NSCLC do not benefit from WBRT, and BSC should be regarded standard of care in these patients. As explained, this does not hold true for younger patients, with li

9、mited or absent extracranial disease, in whom in addition to the possibility of WBRT other treatment approaches including radiosurgery alone or systemic treatment may be indicated as an alternative to WBRT.RTOG-GPA: Graded PrognosticAssessmentsSperduto PW, et al. Int J Radiat Oncol Biol Phys 2010; 7

10、7: 65561.RTOG-GPA: Graded PrognosticAssessmentsSperduto PW, et al. Int J Radiat Oncol Biol Phys 2010; 77: 65561.JCO：Jan. 2017SRS/WBRT/EGFR-TKIGPA:2-3.5&0-1.5?结论与争议 结论：对于不适合行手术/SRS放疗的非小细胞肺癌患者可以选择一激素为主的临床支持治疗，WBRT未必是必选项！ 争议：试验结果的重复性研究？ 扩大样本量，筛选获益亚群？ 改变放疗剂量方法？54Gy？ 淘尽黄沙始现金？期待更多的临床试验告诉我们最靠近真实的答案！本研究

11、的一般描述 a non-inferiority, phase 3 randomised trial done at 69 UK and three Australian centres. NSCLC patients with brain metastases unsuitable for surgical resection or stereotactic radiotherapy optimal supportive care (OSC) including dexamethasone plus WBRT (20 Gy in five daily fractions) or OSC alo

12、ne including dexamethasone The primary outcome measure：quality-adjusted life-years (QALYs). QALYs were generated from overall survival and patients weekly completion of the EQ-5D questionnaire. Between March 2, 2007, and Aug 29, 2014, 538 patients were recruited from 69 UK and three Australian centres, and were randomly as