Background: Graded Prognostic Assessment (GPA) has been proposed for various brain metastases (BMs) tailored to the primary histology and molecular profiles. However, it does not consider whether patients have been operated on or not and does not include surgical outcomes as prognostic factors. The residual tumor burden (RTB) is a strong predictor of overall survival. We validated the GPA score and introduced “volumetric GPA” in the largest cohort of operated patients and further explored the role of RTB as an additional prognostic factor. Methods: A total of 630 patients with BMs between 2007 and 2020 were included. The four GPA components were analyzed. The validity of the original score was assessed using Cox regression, and a modified index incorporating RTB was developed by comparing the accuracy, sensitivity, specificity, F1-score, and AUC parameters. Results: GPA categories showed an association with survival: age (p< 0.001, hazard ratio (HR) 2.9, 95% confidence interval (CI) 2.5–3.3), Karnofsky performance status (KPS) (p< 0.001, HR 1.3, 95% CI 1.2–1.5), number of BMs (p= 0.019, HR 1.4, 95% CI 1.1–1.8), and the presence of extracranial manifestation (p< 0.001, HR 3, 95% CI 1.6–2.5). The median survival for GPA 0–1 was 4 months; for GPA 1.5–2, it was 12 months; for GPA 2.5–3, it was 21 months; and for GPA 3.5–4, it was 38 months (p< 0.001). RTB was identified as an independent prognostic factor. A cut-off of 2 cm3was used for further analysis, which showed a median survival of 6 months (95% CI 4–8) vs. 13 months (95% CI 11–14,p< 0.001) for patients with RTB > 2 cm3and <2 cm3, respectively. RTB was added as an additional component for a modified volumetric GPA score. The survival rates with the modified GPA score were: GPA 0–1: 4 months, GPA 1.5–2: 7 months, GPA 2.5–3: 18 months, and GPA 3.5–4: 34 months. Both scores showed good stratification, with the new score showed a trend towards better discrimination in patients with more favorable prognoses. Conclusion: The prognostic value of the original GPA was confirmed in our cohort of patients who underwent surgery for BM. The RTB was identified as a parameter of high prognostic significance and was incorporated into an updated “volumetric GPA”. This score provides a novel tool for prognosis and clinical decision making in patients undergoing surgery. This method may be useful for stratification and patient selection for further treatment and in future clinical trials.
背景：针对不同原发组织学类型和分子特征的脑转移瘤，已提出分级预后评估（GPA）系统。然而，该系统未考虑患者是否接受过手术治疗，也未将手术结果纳入预后因素。残留肿瘤负荷（RTB）是总体生存期的强预测因子。我们在最大规模的手术患者队列中验证了GPA评分，并引入“体积GPA”，进一步探讨了RTB作为附加预后因素的作用。方法：共纳入2007年至2020年间630例脑转移瘤患者。分析GPA的四个组成部分。通过Cox回归评估原始评分的有效性，并通过比较准确度、敏感性、特异性、F1分数和AUC参数，开发了包含RTB的改良指数。结果：GPA类别与生存期相关：年龄（p<0.001，风险比（HR）2.9，95%置信区间（CI）2.5–3.3）、卡氏功能状态评分（KPS）（p<0.001，HR 1.3，95% CI 1.2–1.5）、脑转移瘤数量（p=0.019，HR 1.4，95% CI 1.1–1.8）以及颅外转移的存在（p<0.001，HR 3，95% CI 1.6–2.5）。GPA 0–1分患者的中位生存期为4个月；GPA 1.5–2分为12个月；GPA 2.5–3分为21个月；GPA 3.5–4分为38个月（p<0.001）。RTB被确定为独立预后因素。以2 cm³为截断值进行进一步分析，结果显示RTB > 2 cm³和<2 cm³患者的中位生存期分别为6个月（95% CI 4–8）和13个月（95% CI 11–14，p<0.001）。将RTB作为附加组成部分纳入改良的体积GPA评分。改良GPA评分的生存率分别为：GPA 0–1：4个月，GPA 1.5–2：7个月，GPA 2.5–3：18个月，GPA 3.5–4：34个月。两种评分均显示出良好的分层能力，新评分在预后较好的患者中显示出更好的区分趋势。结论：原始GPA的预后价值在我们接受脑转移瘤手术的患者队列中得到证实。RTB被确定为具有高度预后意义的参数，并被纳入更新的“体积GPA”。该评分为接受手术的患者提供了新的预后和临床决策工具。该方法可能有助于进一步治疗的分层和患者选择，以及未来临床试验的设计。
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