目标:大约10%的脊柱转移瘤患者发展为转移性硬膜外脊髓压迫(MESCC),未诊断和未治疗的情况会导致步行丧失。及时诊断和有效的多学科治疗对于优化神经系统预后至关重要。这项荟萃分析旨在确定非卧床MESCC患者的最有效治疗方法。
方法:作者对移动MESCC患者的治疗进行了系统评价和荟萃分析,结果描述为局部对照(LC),步行功能,生活质量(QOL),发病率,总生存率(OS)。
结果:总体而言,共纳入54篇论文(4101例患者)。与常规外束放疗(cEBRT)相比,立体定向放疗(SBRT)改善LC的趋势得到了证明:随机效应建模1年LC率86%(95%CI84%-88%)与81%(95%CI74%-86%)(p>0.05),分别,和普通效应建模1年LC率85%(95%CI82%-87%)与76%(95%CI74%-78%)(p<0.05)。手术后辅助放疗,cEBRT或SBRT,与未手术的放疗相比,在LC(OR0.88,95%CI0.65-1.19)或步行功能(OR1.51,95%CI0.83-2.74)方面均无明显益处。与cEBRT相比,手术在QOL方面有显著的益处,此外,SBRT单独提供了QOL的长期改善。治疗类型不是OS的显著预测因子,但完全卧床状态与OS改善显著相关(HR0.46~0.52,相对危险度1.79~2.3).辐射诱发的脊髓病是SBRT的罕见并发症(包括2例患者[0.1%])。与手术相关的发病率相对较高,伤口并发症发生率为10%,硬件故障率为1.6%。
结论:SBRT是一种非常有前途的治疗方式,被整合到治疗算法中并提供持久的LC。在MESCC的流动患者中,手术不能改善LC,生存,或步行功能;尽管如此,手术在生活质量方面有显著的益处.在没有神经功能缺损的MESCC患者中,手术的作用仍有争议,因为研究表明,对于接受SBRT而未接受手术的患者,LC良好.然而,手术可以为在脊髓耐受性的限制下对整个肿瘤体积施用消融剂量的SBRT提供安全的界限。需要进一步的随机对照试验来研究移动MESCC患者在SBRT之前进行手术的益处。凭借分离手术和SBRT的优异效果,鉴于这些手术的并发症发生率和发病率,高侵入性椎体切除术的作用正在减弱。
OBJECTIVE: Approximately 10% of patients with spinal metastases develop metastatic epidural spinal cord compression (MESCC), which left undiagnosed and untreated can lead to the loss of ambulation. Timely diagnosis and efficient multidisciplinary treatment are critically important to optimize neurological outcomes. This meta-analysis aimed to determine the most efficient treatment for ambulatory patients with MESCC.
METHODS: The authors conducted a systematic
review and meta-analysis of the treatment of mobile patients with MESCC in terms of outcomes described as local control (LC), ambulatory function, quality of life (QOL), morbidity, and overall survival (OS).
RESULTS: Overall, 54 papers (4101 patients) were included. A trend toward improved LC with stereotactic body radiotherapy (SBRT) compared with conventional external beam radiotherapy (cEBRT) was demonstrated: random effects modeling 1-year LC rate 86% (95% CI 84%-88%) versus 81% (95% CI 74%-86%) (p > 0.05), respectively, and common effects modeling 1-year LC rate 85% (95% CI 82%-87%) versus 76% (95% CI 74%-78%) (p < 0.05). Surgery followed by adjuvant radiotherapy, either cEBRT or SBRT, showed no significant benefit in either LC (OR 0.88, 95% CI 0.65-1.19) or ambulatory function (OR 1.51, 95% CI 0.83-2.74) compared with radiotherapy without surgery. There was a significant benefit of surgery compared with cEBRT regarding QOL, and furthermore SBRT alone provided long-term improvement in QOL. The type of treatment was not a significant predictor of OS, but fully ambulatory status was significantly associated with improved OS (HR 0.46-0.52, relative risk 1.79-2.3). Radiation-induced myelopathy is a rare complication of SBRT (2 patients [0.1%] in the included papers). The morbidity rate associated with surgery was relatively high, with a 10% wound complication rate and 1.6% hardware-failure rate.
CONCLUSIONS: SBRT is an extremely promising treatment modality being integrated into treatment algorithms and provides durable LC. In mobile patients with MESCC, surgery does not improve LC, survival, or ambulatory function; nonetheless, there is a significant benefit of surgery in terms of QOL. In patients with MESCC without neurological deficit, the role of surgery is still debatable as studies demonstrate good LC for patients who undergo SBRT without preceding surgery. However, surgery can provide safe margins for the administration of the ablative dose of SBRT to the entire tumor volume within the constraints of spinal cord tolerance. Further randomized controlled trials are needed on the benefit of surgery before SBRT in mobile patients with MESCC. With the excellent results of separation surgery and SBRT, the role of highly invasive vertebrectomy is diminishing given the complication rate and morbidity of these procedures.