演題抄録

臓器別シンポジウム

開催概要
開催回
第56回・2018年・横浜
 

分子標的治療の時代の脳転移治療における残された課題

演題番号 : SY16-2

[筆頭演者]
演者)井内 俊彦:1 
[共同演者]
瀬戸口 大毅:1、長谷川 祐三:1、堺田 司:1

1:千葉県がんセンター・脳神経外科

 

Majority of patients with brain metastases (BMs) have extracranial active lesions, and always have a risk to develop new BMs after treatment. Therefore, repeatable treatment such as stereotactic radiotherapy (SRT) and, more recently, targeted therapy (TT) are replacing whole brain radiation therapy (WBRT).
Despite the dramatic response of BMs to TT, this treatment is not curable and collaboration with SRT is required. Furthermore, feasibility of TT is depending upon the timing of BMs. Median time to BMs from diagnosis of original cancer was 35.0 months in Her2-positive breast cancer but 1.5 months in EGFR-mutated lung cancer in our series. As a result, Her2-inhibitors were already used in 83% of the former cases, while TKIs were used only in 18% of the latter cases. Moving target is the other problem of TT, and re-biopsy is required at progression. Recent innovations in neurosurgical technique had realized the minimally-invasive removal of BMs, and contribute to clarify the new target of the treatment.
The effect of immune checkpoint inhibitors (ICPi) had been reported even in cases with BMs, and this treatment is suggested to be widely selected for cancer patients. However, ICPi may raise the risk of radiation necrosis (RN) after SRT. The effect of bevacizumab on RN had been reported, but this agent dose not have insurance indication, and necrotomy should be included in choices.
For cases with multiple BMs, WBRT is still the standard treatment. In such cases, hippocampal sparing WBRT is expected to decrease the risk of neuro-cognitive deterioration after irradiation.
Leptomeningeal carcinomatosis (LMC) is the most devastating complications of cancer. Randomized prospective study for LMC is scarce, but TT shows effect in selected cases. Intra-ventricular injection of methotrexate and/or cytarabine through Ommya reservoir should be considered for most patients with cancer cells in the CSF.

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