-
Meningiomas are also known to
have high somatostatin
生长抑素
receptor
受体
density
密度
allowing for the use of
octreotide
奥曲肽
brain scintigraphy
闪烁扫描技术
to
help delineate extent of disease and to
pathologically
病理地
define
an extra-
axial
超出轴向
lesion.198-200
脑
膜瘤也被
认为
有高
生
长
抑素受体密度
可以
使用
奥曲肽脑闪烁扫描技术来帮
助描
< br>绘病变范围以及
病理上定
义
一<
/p>
个超
过中线轴向的病灶
。
Octreotide imaging
with radiolabeled indium or more recently,
gallium, may be particularly useful in
distinguishing residual
tumor from
post-operative scarring in subtotally
resected/recurrent tumors.
放射性
铟元素或者较新的、镓元素标记的奥曲肽成像，或许特别有益于区分在完整切除残余肿瘤还是手术后的瘢
痕，或者复发的肿瘤
Treatment Overview
治疗综述
Observation
观察
Studies that
examined
检查
the growth
rate
生长速度
of
incidental
偶发
偶然
meningiomas in otherwise
另外的
symptomatic
有症状
的
patients
suggested
建议
that many
asymptomatic
无症状的
meningiomas
may be followed safely
with
serial
连续
brain imaging until
either the tumor enlarges
增大
significantly
明显
or becomes
symptomatic.201, 202
研
究
检查
偶发的另外的有症
状
的
脑
膜瘤病人生长速度在建
议许
多无症
< br>状
性
脑
膜瘤使用连续
脑
成像后可能安全地
,
直
到任何
肿
瘤明显增大或
变
得有症
状
。
These studies confirm
the tenet that many meningiomas grow very
slowly and that a decision not to operate is
justified
合
理地
in
selected asymptomatic patients.
这
些
研
究
证实
的
原则
许
多
脑
膜瘤生
长
非常
缓
慢
,
< br>这决
定
在挑选出
的无症
状
的病人不
进行
操作是
合理的。
As the growth rate is
unpredictable in any individual, repeat brain
imaging is mandatory to monitor an incidental
asymptomatic meningioma.
但是
任何个体的生长速度是不可预知的，反复
强制性
进行脑成像
来监测偶发的雾症状的脑膜瘤
Surgery
The treatment of
meningiomas is dependent upon both patient-related
factors (age, performance status, medical
co-
morbidities) and treatment-related
factors (reasons for symptoms, resectability and
goals of surgery).
脑
膜瘤的治
疗
取
决
于
与
患者
相关的
因素
(
年
龄
、性能
状况
、
医学
联合发病率
)
和治
疗
相
关
的因素
(
症
状
原
因<
/p>
,resectability
可治愈性和
外科手
术
的
目
标
)
。
Most patients diagnosed with
surgically-accessible symptomatic meningioma
undergo surgical resection to relieve
neurological symptoms.
大多
数
病人被
诊断为
可
手
术
的有症
状
的
脑
膜瘤
经历
手
术
切除
缓
解
神
经
症
状
。<
/p>
Complete surgical resection
may be curative and is therefore the treatment of
choice.
完成手
术
切除可能
治愈的
,
所以是治
疗
< br>的首
选
。
Both the tumor grade and the extent of
resection impact the rate of recurrence.
< br>肿
瘤分
级
和
切除的范围
影
响复发
的
几率
。
In a
cohort
同期组群
of 581 patients,
10-year progression-free survival was 75%
following GTR(gross total resection ) but
dropped to 39% for patients receiving
subtotal resection.203
在一个<
/p>
581
个病人的同期组群中，接受完全切除的患者
10
年无进展生存率是
75%
，但接受次全切除的病人下降到
39%
。
Short-term recurrences reported for
grade I, II, and III meningiomas were 1% to 16%,
20% to 41%, and 56% to 63%,
respectively.204-206
据报道短期的复发率
在
1
、
2
、
< br>3
级脑膜瘤分别是
1% to 16%, 20% to
41%, and 56% to 63%,
The
Simpson classification scheme that evaluates
meningioma surgery based on extent of resection of
the tumor and its
dural attachment
(grades I to V in decreasing degree of
completeness) correlates with local recurrence
rates.207
辛普森分
类<
/p>
方案
,
评
估
脑
膜瘤手
术
基于<
/p>
肿
瘤切除
范围
及
硬脑膜的附件
(1
至
< br>V
级
在
减
少的完全程度
)
与
局部
复发
率
的关
系
First proposed in 1957, it is
still being widely used by surgeons today.
在
1957
年首次提出
,
今天
它
仍被
外科
医
生广泛使用。
Radiation therapy
放疗
Safe GTR is
sometimes not feasible due to tumor location.
因为肿瘤位置
安全的完整切除有时候是不可行的
In this case, subtotal resection
followed by adjuvant
EBRT
（
external beam radiation
therapy
）
has been shown to
result in
long-term survival comparable
to GTR (86% vs. versus 88%, respectively),compared
to only 51% with incomplete resection
alone.208
在
这种
情
况
下
，次全
切除
,
然后行
辅
助
外放射治疗
已被
证
明
导
致
与完全切除相近的长
期生存
(
分
别
是
86%
比
88%),
而单
纯的
不完整切除只有
51%
。
Of 92 patients with grade I tumors,
Soyuer and colleagues found that radiation
following subtotal resection reduced
progression compared to incomplete
resection alone, but has no effect on overall
survival.209
92
位
1
级肿瘤的患者，
Soyuer
和他
的同事们发现
,
次全切除后放疗相比单纯不完全切除减少肿瘤进
展
,
但不影响总
的生存
Because high grade meningiomas
have a significant probability of recurrence even
following GTR,210 postoperative
high-
dose EBRT (above 54 Gy) has become
the accepted standard of care for these tumors to
improve local control.211
因
为高级别脑膜瘤甚至在完全切除后仍有很高的复发几率，手术后大剂量的外放射治疗（超过
54GY
）已经成为改
善肿瘤局部控制率的公认的标准
A review of 74 patients showed
that adjuvant radiotherapy improves survival in
patients with grade III meningioma and in
those with grade II disease with brain
invasion.212
一项
7
4
名患者的回顾研究显示辅助放疗改善了
3
级脑膜瘤患者的生存，这些患者存在
2
级的脑浸润病变
The role of post-GTR
radiotherapy in benign cases remains
controversial.
完全切除之后的放射治疗的角色良性情况下存在争议
Technical advances have enabled
stereotactic administration of radiotherapy by
linear accelerator (LINAC), Leksell Gamma
Knife
or Cyberknife
radiosurgery.
技
术
进
步使立体定向放射治
疗实施
由直
线
加速器
(
直
线
加速器
),
立体
定向伽
玛
刀
或射波刀
< br>放射外科。
The use of
stereotactic radiotherapy (either single fraction
or fractionated) in the management of meningiomas
continues
to evolve. Advocates have
suggested this therapy in lieu of EBRT for small
(<35 mm) recurrent or partially resected tumors.
使用立体定向放射治
疗
(
无
论
是
单部分
或
分组
)
在
脑
膜瘤
的治疗中
得以持
续发
展。
这
一
疗
法的倡
导
者建
议
代替
外放射
治疗
对于
小
(< 35
毫米
)
复发
或部分切除
的肿
瘤。
In addition, it
has been used as primary therapy in surgically
inaccessible tumors (i.e. base of skull
meningiomas) or in
patients deemed poor
surgical candidates because of advanced age or
medical co-morbidities.
此外
,
作
为
无法手
术
的肿
瘤
的
主要治
疗
(
例如
头
盖骨
为基础脑
膜瘤
)
< br>或在病人
认为
因
为
高
龄
老人和
医疗
共病
难以手术
。
A study of about 200 patients compared
surgery with SRS as primary treatment for small
meningiomas.213
一
项关
于
200
例患者手
术
相比
与
SRS
作
为
主要治
疗
小
脑
膜瘤
The SRS
arm had similar 7-year progression-free survival
compared to GTR and superior survival over
incomplete resection.
SRS
组相
比完全切除具有相似的
7
年雾进展生存，相比不完全切除有较高
生存
In another study,
Kondziolka and colleagues followed a cohort of 972
meningioma patients managed by SRS over 18
years.214
在另一
项研
究中
,Kondziolka
及其同事追踪
了一
组
972
名
SRS
治疗的
脑
膜瘤患者
超
过
18
年。
Half of
the patients have undergone previous surgery.
一半的病人
之前
接受
过
手
术
。
SRS provided excellent tumor control
(93%) in patients with grade I tumors.
SRS
为
一
级肿
瘤患者
提供了卓越的
肿
瘤控制
(93%)
。
For grade II and III meningiomas, tumor
control was 50% and 17%, respectively.
对
于等
级
II
和
III
脑
膜瘤
,
肿
瘤控制分
别
< br>是
50%
和
17%
。
These results suggest
that stereotactic radiation is effective as
primary and salvage treatment for meningiomas
smaller than
3.5 cm.
这
些
结
果表明
,
立体定向放射治
疗对于
小于
3.5
厘米
脑
膜瘤
的初始及抢救性治疗是
有效的
。
Systemic therapy
全身治疗
Notwithstanding limited data,
hydroxyurea has been modestly successful in
patients with recurrent meningiomas.215
虽
然
数
据有限
,
羟
基
脲
都
类治疗复发
性
脑
膜瘤
患者是
成功
的
< br>。
Targeted therapies that
have shown partial efficacy in refractory
meningiomas are somatostatin analogues and alpha
interferon.
靶
向
治疗
已
经
表明
在难治性脑膜瘤中有
部分
效果的是
生
长
抑素
类
似物和α干
扰
素。
NCCN Recommendations
推荐
Initial
treatment
初始治疗
Meningiomas are typically diagnosed by
CT or MRI imaging.
脑
膜瘤通常
由
CT
或
MRI
成像
诊断
。
Biopsy or octreotide scan may be
considered for confirmation.
活
< br>检
或
奥曲肽扫
描
可以被当成证据
。
For
treatment planning, multidisciplinary panel
consultation is encouraged.
为制定
治
疗计划
、多
学
科小
组会诊
是
被
鼓
励的
。
Patients are stratified by the presence
or absence of symptoms and the tumor size.
Most asymptomatic patients
with small tumors (< 30 mm) are best managed by
observation.
If neurologic impairment is imminent,
surgery (if accessible) or radiotherapy (EBRT or
SRS) is feasible.
Asymptomatic tumors 30 mm or larger
should be surgically resected or observed.
Symptomatic disease
requires active treatment by surgery whenever
possible.
Non-surgical
candidates should undergo radiation.
Regardless of tumor size and symptom
status, all patients with surgically resected
grade III meningioma (even after GTR)
should receive adjuvant radiation to
enhance local control.
Following subtotal resection, radiation
should be considered for small, asymptomatic grade
II tumors and for large grade I
and II
tumors.
SRS may be used in
lieu of conventional radiation as adjuvant or
primary therapy in asymptomatic cases.
Follow-up and recurrence
In the absence of data,
panelists have varying opinions on the best
surveillance scheme and clinicians should follow
patients
based on individual clinical
conditions.
Generally,
malignant or recurrent meningiomas are followed
more closely than grades I and II tumors.
A typical schedule for low
grade tumors is MRI every 3 months in year 1, then
every 6 to 12 months for another 5 years.
Less frequent imaging is
required beyond 5-10 years.
Upon detection of recurrence, the
lesion should be resected whenever possible,
followed by radiation.
Non-surgical candidates should receive
radiation.
Chemotherapy is reserved for patients
with an unresectable recurrence refractory to
radiotherapy.
Brain
Metastases
脑转
移
Metastases to the brain are
the most common intracranial
[,intr?'kreini?l]tumors in adults and occur ten
times more
frequently than do primary
brain tumors.
Metastases to the brain
are the most common
intracranial
颅内
的
[,intr?'kreini?l]tumors in
adults
成人
and
occur
存在
ten
times
十倍
more
frequently
频
繁
than
do primary brain tumors.
脑转
移
是最常
见
的成人
颅内肿
瘤，
频
率（
发
病率）是原
发脑肿
瘤的十倍。
More recent population-based data
reported that about 8%to 10%of cancer patients are
inflicted by symptomatic
metastatic
tumors in the brain.
More
recent
较
新的
population-based data reported that about 8%to
10%of cancer patients are inflictedvt.
造成；使遭受
（
损伤
、痛苦等）；
给
予（打
击
等）<
/p>
by symptomatic metastatic tumors in
the brain.
最近的以人群
为
基
础
的
数
据
报
道
,
大
约
8%
至
10%<
/p>
的癌症患者都存在有症
状
的
脑转
移瘤。
A much
higher incidence upon
autopsy
尸
检
has
been reported.
据
报
道
经过
尸体解剖
发
生率要高得多。
As a result of
advances in the diagnosis and treatment,most
patients improve with treatment and do not die of
these
metastatic lesions.
因<
/p>
为诊断
和治
疗发
展
,
大多
数
病
人通
过
治
疗
好
转
,
不
会
死于
这
些
转
移病
灶
。
Primary lung cancers are the most
common source,accounting for half of intracranial
[,intr?'kreini?l] metastases,although
melanoma
黑色素瘤
has
been documented to have the highest
predilection
偏
爱
to
spread to the brain.
原
发
性肺癌是最常
见
的
来
源
,
占一半的
颅内
转
移
,
尽
管黑
色素瘤被
证
明是最偏
爱扩
散到大
脑
。
Diagnosis of CNS
involvement
损伤
is becoming
more common in patients with breast cancer as
therapy for metastatic
disease is
improving.220
因
为转
移性疾病治
疗
的改
进
< br>，乳腺癌患者中
枢
神
经
系
统损伤
的
诊断
日
趋
常
见
。
Almost 80%brain
metastases occur in the cerebral hemispheres,an
additional 15%occur in the cerebellum,and 5%occur
in
the brainstem.221
几乎
80%
的
脑转
移
发
生
在大
脑
半球
,
额
外的
15%
发
生在小
脑
,5%
发
< br>生在
脑
干
These lesions typically follow a
pattern of hematogenous spread to the gray-white
junction where the relatively narrow
caliber of the blood vessels tends to
trap tumor emboli.
These lesions
病
变
typically
代
表性
follow a
pattern
模式
of hematogenous sp
read
血行
转
移
to the gray-white junction
结
合部
where
the relatively
相
对
narrow caliber
管
径
of the blood
vessels tends
趋势倾
向
to trap
陷
阱
捕
获
tumor
emboli
肿
瘤栓子
.
这种
病
变
代表性的遵循血
行
转
移模式侵及灰白
质结
合
处
，有相
对狭
窄的血管管
径
，有成
为肿
瘤栓子陷
阱倾
向的，
< br>
The majority of cases have multiple
brain metastases evident on MRI scans.
大多
数
情
况
下
多
发脑转
移在磁共振
扫
描明
显显
影。
The presenting signs and symptoms of
metastatic brain lesions are similar to those of
other mass lesions in the brain,such as
headache,seizures,and neurological
impairment.
转
移性
脑<
/p>
部病
变
表
现
的症
状
和体征
与脑
部大多
数
的病
变
相似
,
如
头
痛、
癫痫发
作、和神
< br>经损伤
。
Treatment
Overview
综诉
Surgery
Advances
in surgical technique have rendered upfront
resection followed by WBRT the standard of care
for solitary brain
metastases.
< br>手
术
技
术
的
进
步提出前期手
术
切除，然后行全
脑
放
疗
，成
为单发脑转
移的
标
准治
疗
A
retrospective analysis of 13,685 patients admitted
for resection of metastatic brain lesions showed a
decline in in-hospital
mortality from
4.6%in the period 1988-1990 to 2.3%in the period
1997-2000.222
High-volume
hospitals and surgeons produced superior outcomes.
Patchell and his group
conducted a study that randomized 95 patients with
single intracranial metastases to complete
resection alone or surgery plus
adjuvant WBRT.223
Postoperative radiation was associated
with dramatic reduction in tumor recurrence(18%vs
70%;P<0.001) and likelihood of
neurologic deaths(14%vs 44%;P=0.003).
Overall survival,a
secondary endpoint,showed no difference between
the arms.
Comparison of surgery plus WBRT versus
WBRT alone is discussed in the WBRT section.
In the case of multiple
lesions,the role of surgery is more restricted to
obtaining biopsy samples or relieving mass effect.
However,evidence from
retrospective series suggested survival benefits
from tumor resection for selected patients of good
prognosis with up to three metastatic
sites.224,225
Stereotactic
radiosurgery
The advent of
SRS offered a minimally invasive option as opposed
to ts undergoing SRS avoid the risk of
surgery-related morbidity.
Late side effects such as edema and
radiation necrosis are uncommon.226
SRS is mostly successful for small,deep
tumors.
In a randomized
Japanese study of 132 patients with 1 to 4
metastatic brain tumors smaller than 3 cm,addition
of WBRT to
SRS did not prolong median
survival compared to SRS alone(7.5 months vs.8.0
months,respectively).227
However,1-year brain recurrence rate
was lowered in the WBRT plus SRS
arm(47%vs.76%;P<0.001).
This likely served to decrease the need
for salvage therapy in this group (10/65)compared
to patients receiving no upfront
WBRT(29/67).
Retrospective comparative studies
showed that SRS plus WBRT resulted in equivalent
if not better survival compared with
surgery and WBRT.228-230
SRS also conferred a significant
improvement in local control,especially for
patients with radiosensitive tumors or solitary
brain lesions.
SRS alone compared to resection plus
WBRT was evaluated in a randomized controlled
trial by Muacevic et al.231
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