Brain Metastases in Lung Cancer: Still Room to Personalize Care
http://cancergrace.org/lung/2011/09/11/brain-metastases-in-lung-cancer-still-room-to-personalize-care/
For non-small cell lung cancer patients with multiple brain metastases, the standard approach of whole brain radiotherapy is not necessarily standard for each and every patient. Each patient’s specific situation may sometimes be best approached with various combinations of surgery, radiation, medical/systemic therapy, and non-cancer directed treatment.
The best course of treatment depends on many factors. Key aspects of a patient’s situation include age, how well the patient is doing in general, whether they have other sites of metastasis other than the brain (and whether those sites harbor active cancer), how extensive the brain metastases are in size and number, and whether they are experiencing symptoms.
Symptoms are often caused by swelling in and around the brain metastasis which then compresses the normal healthy brain. Steroid medication such as dexamethasone is helpful in reducing such swelling. In some situations, surgical decompression can dramatically relieve swelling, and accomplish relief of edema quickly. Indeed, this is one of the great benefits of surgery in the setting of multiple brain metastases.
In general, for patients with more extensive intracranial and extracranial disease, whole brain irradiation offers broad regional control of brain metastases – by itself or following surgical resection brain lesion(s). In the short term, whole brain radiotherapy can cause hair loss, headache, fatigue, nausea, and Eustachian tube dysfunction. In the long term, the greatest side effects are upon short term memory and the ability to multitask.
An alternative to whole brain irradiation in some circumstances is stereotactic radiosurgery – a focused approach targeting known areas of brain metastases. Stereotactic radiosurgery can be accomplished with multiple devices – Gamma Knife and Cyberknife are examples of dedicated stereotactic radiosurgery platforms. For patients that present with a solitary or limited brain metastasis, there is a fifty percent chance they will develop other brain metastases and may eventually benefit from whole brain irradiation. There does not seem to be a detriment to initially deferring whole brain irradiation in favor of stereotactic radiotherapy for these patients. For patients with more extensive brain metastases, the risk of developing additional brain metastases is likely higher.
Where exactly the line is drawn between “limited” vs. “more extensive” brain metastases is not clear. In some studies, patients with up to 3 or 4 brain metastases were considered to have “limited disease.” For patients with more extensive metastatic brain disease, consideration of stereotactic radiosurgery as an alternative to whole brain irradiation or in addition to whole brain radiation revolves around assessment of the tempo of the cancer and the patient’s general fitness. In circumstances where the cancer is generally otherwise controlled and the patient is otherwise fit, healthy, and active, it is reasonable to lead treatment with a stereotactic approach and reserve whole brain irradiation, or to perhaps lead with whole brain irradiation with consideration of using stereotactic radiosurgery to control dominant lesion.
In the context of radiosurgery, careful monitoring for additional metastases is often emphasized. I agree, however, I also recommend that for patients otherwise generally doing well, that I also would monitor the brain with subsequent MRIs after whole brain irradiation. Even after whole brain irradiation, there remains about a one-in-four chance of developing new metastases.
In situations where patients have active disease otherwise, stereotactic radiosurgery may sometimes be used to rapidly accomplish treatment prior to starting systemic therapy – stereotactic radiosurgery is often accomplished in a single half-day, as opposed to the multi-week schedule typical of whole brain irradiation. In this circumstance as well, stereotactic radiotherapy can enable deferment of potential whole brain associated side effects.
All of these decisions and considerations are of course made importantly in the context of a patient’s goals, and their circumstance. For patients suffering from extensive disease from which they are likely to succumb in the near term, whole brain irradiation followed by symptom directed medical and non-medical therapy is often the best plan.
本帖最后由 老马 于 2013-12-3 16:54 编辑
马哥辛苦了
很好的贴子。
我发现好多吃靶向药耐药的最直接反映就是脑部有发展。太恐怖了。:funk:
学习了，收益匪浅。
颅骨与脑间有三层膜。由外向内为硬脑膜、蛛网膜和软脑膜；三层膜合称脑膜。他们具有保护和支持的作用，并通过被膜的血管使脑和脊髓得到营养。
（1）硬脑膜是一厚而坚韧的双层膜。外层是颅骨内面的骨膜，仅疏松地附于颅盖，特别是在枕部与颞部附着更疏松，称为骨膜层。但在颅的缝和颅底则附着更牢固，很难分离。颅内无硬膜内腔。硬脑膜内层较外层厚而坚韧，与硬脊膜在枕骨大孔处续连，称为脑膜层。主要作用是保护大脑。
硬脑膜内层在某些部位形成一些板状隔，分隔颅腔，伸入各脑部之间的特殊结构：1大脑镰 2小脑幕 3小脑镰 4鞍隔
俩层硬脑膜在一些部位彼此分开，在腔隙内面衬有内皮细胞形成硬脑膜窦：1上矢状窦2下矢状窦3直窦4横窦和乙状窦5窦汇枕窦6海绵窦7岩上窦和岩下窦
硬脑膜的外层与颅盖骨结合疏松，当颅盖骨发生骨折或此处硬脑膜血管损伤时，在硬脑膜与颅骨之间，极易形成硬膜外血肿。
硬脑膜外层与颅底骨结合紧密，若颅底骨折时，易将硬脑膜和蛛网膜同时撕裂而发生脑脊液外露。如颅前窝骨折，脑脊液可能流入鼻腔，形成鼻漏。
脑的静脉血先注入硬脑膜窦内，最终引流至颈内静脉，而窦壁无平滑肌，不能收缩，若受到损伤则出血难止，容易形成颅内血肿。
海绵窦与周围的静脉有广泛的交通（如右下图所示），面部感染和腹部盆腔感染都可以蔓延至海绵窦，造成颅内感染。
（2）蛛网膜：薄而透明，无血管和神经，包绕整个脑，但不深入脑沟内。该膜与硬脑膜间为潜在的间隙，易分离；与软脑膜之间有许多结缔组织小梁相连，其间为蛛网膜下隙，内含脑脊液和较大的血管。该隙通过枕骨大孔处与脊髓蛛网膜下隙相通。
蛛网膜下池：蛛网膜除随大脑镰和小脑幕分别伸入大脑纵裂和大脑横裂外，均跨过脑的其他沟裂而不伸入其中，致使脑蛛网膜下隙在某些部位扩大成为蛛网膜下池。其中最大的是在小脑与延髓背面之间的小脑延髓池。临床上可在此进行蛛网膜下隙穿刺。
蛛网膜颗粒：脑蛛网膜在上矢状窦的两侧形成许多绒毛状突起，突入上矢状窦内称为蛛网膜颗粒。脑脊液通过这些颗粒渗入硬脑膜窦内，回流入静脉。
（3）软脑膜是紧贴于脑表面的一层透明薄膜，血管丰富，并伸入沟裂。脑的血管在软脑膜内分支呈网，并进入脑实质浅层，软脑膜也随血管进入至脑实质一段。由软脑膜形成的邹襞突入脑室内，形成脉络丛，分泌脑脊液。软脑膜对脑起着重要的营养作用。
一、头痛的病因
（1）颅脑病变
感染：各种脑膜炎、脑膜脑炎、脑炎、脑脓肿、脑结核病、脑寄生虫病、中毒性脑病
血管病变：蛛网膜下腔出血、脑出血、脑血栓形成、脑栓塞、高血压脑病、脑供血不足，颅内动脉瘤、脑血管畸形、颅内静脉窦血栓形成、血栓闭塞性脉管炎
占位性病变：脑肿瘤、颅内转移瘤、脑结核瘤、颅内白血病浸润、颅内囊虫病或包虫病
颅脑外伤：脑震荡、脑挫伤、硬脑膜下血肿、颅内血肿、脑外伤后遗症
其它 偏头痛、丛集性头痛、头痛型癫痫、腰椎穿刺后及腰椎麻醉后头痛
（2）颅外病变
颅骨疾病：颅底凹入症、颅骨肿瘤
颈椎病及其他颈部疾病
神经痛：三叉神经、舌咽神经及枕神经痛
眼、耳、鼻和齿疾病所致的头痛
肌收缩性头痛
（3）全身性疾病
急性感染 流感、伤寒、炎症等发热性疾病
心血管疾病 原发性高血压、心力衰竭
中毒 铅、酒精、一氧化碳、有机磷、药物中毒
其它 尿毒症、低血糖、贫血、肺性脑病、系统性红斑狼疮
（4）神经官能症
二、头痛的发病机制
（1）血管因素：各种原因引起的颅内外血管的收缩、扩张以及血管受牵引或伸展
（2）脑膜受刺激或牵拉
（3）具有痛觉的脑神经（三叉、面、舌咽、迷走）和1、2、3颈神经被刺激、挤压或牵拉
（4）其他 如头颈部肌肉的收缩，五官和颈椎病变，生化因素及内分泌紊乱，神经功能紊乱等
（5）头部敏感组织神经纤维异常的过度放电活动或这些结构放电正常但心理反应异常。
老马老师，肺腺癌脑转，特罗凯控制住了癌胚原正常，原发灶几乎看不出来，8月份核磁复查，脑转有改变，可近两天，出现头晕，不知是否是脑转有进展，单纯吃的止晕的能行吗？还是再做核磁。麻烦！