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Diagnosis and Treatment Experience of Multidisciplinary Team for Brain Metastasis in Peking Union Medical College Hospital: A Summary of 159 Cases
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摘要:
目的 脑转移瘤患者预后差且缺乏统一的诊疗规范, 对多学科协作(multidisciplinary team, MDT)诊疗需求极高。通过总结北京协和医院脑转移瘤MDT诊疗经验, 以期为临床提供参考。 方法 回顾性纳入2019年1月—2021年12月北京协和医院神经肿瘤中心所有行脑转移瘤MDT诊疗的患者。对其入组时临床特征、诊疗决策、治疗依从性、临床预后等进行归纳、总结, 并分析脑转移瘤患者预后的影响因素。 结果 共纳入行脑转移瘤MDT诊疗的患者159例(非脑转移瘤患者13例)。肿瘤来源最多见于肺癌(61.6%), 其次为乳腺癌(11.3%)。绝大部分患者(87.4%)仅接受1次MDT诊疗。行初次脑转移瘤MDT诊疗时, 患者的主要特征为首要诊断为脑转移瘤(90.6%)、一般状况较好(Karnofsky功能状态评分≥70分, 79.2%)、年龄≤65岁(78.6%)、有原发部位或颅内转移灶病理结果(67.9%)、肿瘤来源为肺癌(61.6%)、颅内单发病灶(54.1%)。76.7%(122/159)的患者经MDT诊疗达成了具体的治疗建议, 9.4%(15/159)的患者诊断结果发生改变, 随访1年时完全遵从MDT诊疗建议的患者占比56.6%(90/159)。146例脑转移瘤患者6个月生存率为85.6%(125/146), 1年生存率为78.8%(115/146)。Kaplan-Meier生存曲线显示, 递归分隔分析分级与分级预后评估评分对脑转移瘤患者预后分层有指导意义。多因素Cox回归分析结果显示, 女性(HR=0.437, 95% CI: 0.231~0.828)、完全遵从MDT诊疗建议(HR=0.498, 95% CI: 0.264~0.942)的脑转移瘤患者通常可获得较好的预后。 结论 应设置合理的脑转移瘤患者入组条件, 以提高MDT诊疗效率。多数患者经MDT诊疗后可达成具体的治疗建议, 患者治疗依从性良好。MDT诊疗可能有助于患者总体生存率的提高, 但确切获益情况需进行个体化评估。 Abstract:Objective The prognosis of patients with brain metastases is poor and lacking in unifieddiagnosis and treatment standards. The demand for multidisciplinary team(MDT) diagnosis and treatment mode is extremely high. This study retrospectively summarizes the data of patients treated with MDT for brain metastases in order to provide clinical reference. Methods All patients undergoing MDT treatment for brain metastases at the Neurological Tumor Center of Peking Union Medical College Hospital from January 2019 to December 2021 were retrospectively included. The clinical characteristics, diagnosis and treatment decisions, treatment compliance, clinical prognosis, etc. at the time of enrollment were summarized, and the influencing factors of patients' prognosis were analyzed. Results A total of 159 patients who underwent MDT for brain metastases were included(13 cases with non-cerebral metastases). The most common source of tumor was lung cancer(61.6%), followed by breast cancer(11.3%). The vast majority of patients(87.4%) received only 1 MDT visit. The main characteristics of patients at the time of the initial MDT consultation for brain metastases were primary diagnosis of brain metastases(90.6%), good general condition(Karnofsky functional status score ≥70, 79.2%), age ≤65 years(78.6%), pathological findings of primary site or intracranial metastases(67.9%), tumor origin of lung cancer(61.6%), and single intracranial lesion(54.1%). 76.7%(122/159) of the patients reaching specific treatment recommendations after MDT diagnosis and treatment, 9.4%(15/159) of the patients having changes in diagnosis, and 56.6%(90/159) of the patients exercising full compliance with MDT diagnosis and treatment recommendations at the time of 1-year follow-up. The 6-month survival rate of the 146 patients with brain metastases was 85.6%(125/146) and the 1-year survival rate was 78.8%(115/146). Kaplan-Meier survival curve showed that recursive partition analysis grading and grading prognosis evaluation score had guiding significance for prognosis stratification of patients with brain metastases. Multivariate Cox regression analysis showed that women(HR=0.437, 95% CI: 0.231-0.828) and patients with brain metastases who fully complied with MDT diagnosis and treatment recommendations(HR=0.498, 95% CI: 0.264-0.942) generally had a better prognosis. Conclusions It is necessary to set reasonable conditions for patients with brain metastases to be enrolled in order to improve the diagnosis and treatment efficiency of MDT. Most patients with brain metastases reached specific treatment recommendations after MDT diagnosis and treatment, and the patients had good treatment compliance. The diagnosis and treatment of MDT may help improve the overall survival rate of patients, but the exact benefits need to be evaluated individually. -
Key words:
- brain metastases /
- multidisciplinary team /
- treatment decision /
- prognosis
作者贡献：石易鑫负责撰写论文；王月坤、邢昊负责研究设计；王月坤负责数据分析；邢昊、牛佩负责临床数据整理；陈雯琳、刘德临、赵炳昊、阳天睿负责对患者进行随访；牛佩负责对论文提出批判性建议；马文斌、王裕提供研究思路、负责论文修订。利益冲突：所有作者均声明不存在利益冲突 -
图 4 1例经5次MDT诊疗患者治疗前后颅脑MRI影像学改变
A.治疗前MRI示残腔周围及右颞叶多发占位，内含出血成分，周围脑组织大片水肿，提示肾细胞癌脑转移复发；B.治疗6个月后MRI示左顶叶及右颞叶病灶获得显著改善，水肿范围明显减小
MDT: 同图 1表 1 159例患者初次行脑转移瘤MDT诊疗时临床资料及诊疗结果
指标 数值 KPS评分[n(%)] ≥70分 126(79.2) 60~＜70分 19(11.9) 50~＜60分 14(8.8) 肿瘤来源[n(%)] 肺癌 98(61.6) 乳腺癌 18(11.3) 肾细胞癌 8(5.0) 结直肠癌 7(4.4) 其他* 13(8.2) 未明确/非脑转移瘤# 15(9.4) 颅内转移灶数目[n(%)] 1个 86(54.1) ≥2个 73(45.9) 颅内转移灶最大径ζ[M(P25, P75)，cm] 2.6(1.7，3.5) 原发部位或颅内转移灶病理结果[n(%)] 有 108(67.9) 无 51(32.1) 颅外转移灶[n(%)] 有 67(42.1) 无 92(57.9) RPA分级†[n(%)] Ⅰ级 39(26.7) Ⅱ级 76(52.1) Ⅲ级 31(21.2) GPA评分§[n(%)] 0~1分 40(30.1) 1.5~2.5分 63(47.4) 3~4分 30(22.5) 自明确脑转移瘤诊断至MDT诊疗的时间[M(P25, P75)，d] 36(15，400) MDT诊疗次数[n(%)] 1次 139(87.4) ≥2次 20(12.6) 诊疗依从性[M(P25, P75)，%] 76.4(66.5，100) 随访结果[n(%)] 失访 25(15.7) 未失访 134(84.3) *包括肝脏、甲状腺、子宫、卵巢、胆道系统以及胰腺肿瘤；#包含非脑转移瘤患者13例、明确为脑转移瘤但原发灶不明患者2例；ζ67例患者信息缺失(肿瘤直径不可测量)；†针对146例脑转移瘤患者；§针对146例脑转移瘤患者(2例脑转移瘤但原发灶不明患者及11例信息缺失者无法计算GPA评分)；MDT：同图 1；KPS：Karnofsky功能状态；RPA：递归分隔分析；GPA：分级预后评估 
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表 2 患者基线资料对MDT决策及治疗方式的影响[%(n/N)]
指标 治疗方案 手术(n=61) 化疗(n=40) 放疗(n=68) 靶向治疗/免疫治疗(n=81) KPS评分 ≥70分(n=126) 40.5(51/126) 23.0(29/126) 46.8(59/126) 53.2(67/126) ＜70分(n=33) 30.3(10/33) 33.3(11/33) 27.3(9/33) 42.4(14/33) 颅内病灶数目 单发(n=86) 41.9(36/86) 18.6(16/86) 37.2(32/86) 46.5(40/86) 多发(≥2，n=73) 34.2(25/73) 32.9(24/73) 49.3(36/73) 56.2(41/73) 颅内转移灶最大径* ＜3 cm(n=55) 45.5(25/55) 18.2(10/55) 43.6(24/55) 52.7(29/55) ≥3 cm(n=37) 45.9(18/37) 40.0(15/37) 37.8(14/37) 43.2(16/37) 年龄 ≤65岁(n=125) 40.8(51/125) 25.6(32/125) 41.6(52/125) 54.4(68/125) ＞65岁(n=34) 29.4(10/34) 23.5(8/34) 47.1(16/34) 38.2(13/34) 原发部位或颅内转移灶病理结果 有(n=108) 40.7(44/108) 22.2(24/108) 46.3(50/108) 47.2(51/108) 无(n=51) 33.3(17/51) 31.4(16/51) 35.3(18/51) 58.8(30/51) 肿瘤来源# 肺癌(n=98) 37.8(37/98) 22.4(22/98) 42.9(42/98) 53.1(52/98) 非肺癌(n=46) 39.1(18/46) 32.6(15/46) 50.0(23/46) 56.5(26/46) RPA分级† Ⅰ~Ⅱ(n=115) 39.1(45/115) 22.6(26/115) 47.8(55/115) 57.4(66/115) Ⅲ(n=31) 29.0(9/31) 38.7(12/31) 32.3(10/31) 38.7(12/31) GPA评分§ 3~4分(n=30) 50.0(15/30) 26.7(8/30) 56.7(17/30) 70.0(21/30) 0~2.5分(n=103) 33.0(34/103) 25.2(26/103) 42.7(44/103) 51.5(53/103) MDT：同图 1；KPS、GPA、RPA：同表 1；*67例患者信息缺失(肿瘤直径不可测量)；#13例患者经MDT诊疗后诊断为非脑转移瘤，2例患者经MDT诊疗确诊为脑转移瘤但原发灶部位未知；†针对146例明确脑转移瘤患者；§2例脑转移瘤但原发灶不明患者及11例信息缺失者无法计算(针对146例脑转移瘤患者)
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