Local disease control for spinal metastases following "separation surgery" and adjuvant hypofractionated or high-dose single-fraction stereotactic radiosurgery: outcome analysis in 186 patients.
Local disease control for spinal metastases following "separation surgery" and adjuvant hypofractionated or high-dose single-fraction stereotactic radiosurgery: outcome analysis in 186 patients.
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DOI：
10.3171/2012.11.spine12111
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发表时间：
2013-03
期刊：
影响因子：
--
通讯作者：
Bilsky MH
中科院分区：
文献类型：
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作者：
Laufer I;Iorgulescu JB;Chapman T;Lis E;Shi W;Zhang Z;Cox BW;Yamada Y;Bilsky MH
减压手术后辅助放疗是保留或恢复神经功能并实现转移性硬膜外脊髓压迫患者持久局部疾病控制的有效疗法。作者检查了术后图像引导调强放射治疗 (IG-IMRT) 作为单次分割或大分割立体定向放射外科 (SRS) 实施的结果，以实现长期局部肿瘤控制。一项回顾性图表审查确定了 186 名因脊柱转移瘤而出现硬膜外脊髓压迫的患者，这些患者接受了手术减压、器械治疗和术后放疗，其中 40 名患者 (22%) 接受单次分割 SRS (24 Gy)，37 名患者 (20%) 接受高剂量大分割 SRS（3 次分割 24-30 Gy），或低剂量大分割 SRS (18-36 名患者) 109 名患者 (58%) 接受 5 或 6 次 Gy 治疗。通过竞争风险分析评估术后辅助SRS剂量和分割、患者特征、肿瘤组织学特异性放射敏感性、硬膜外脊髓受压程度、手术减压程度、术前放疗反应和局部肿瘤控制之间的关系。 SRS 后一年局部进展的总累积发生率为 16.4%。多变量格雷竞争风险分析显示，与低剂量大分割 SRS（1 年局部进展 22.6%；HR = 1）相比，高剂量大分割 SRS 的局部控制显着改善（1 年局部进展累积发生率为 4.1%；风险比 = 0.12，p = 0.04）。尽管单变量分析表明，与术前未接受任何放疗的患者（1 年局部进展 11.2%，HR = 1）相比，术前 cEBRT 失败的患者（1 年局部进展 22.2%，HR = 1.96，p = 0.07）存在局部进展风险更大的趋势，但多变量分析并未证实这种关联。没有其他变量与无进展生存期显着相关，包括肿瘤组织学的放射敏感性、硬膜外脊髓受压程度、手术减压程度或性别。无论肿瘤组织学特异性的放射敏感性如何，硬膜外脊髓减压和器械术后辅助 SRS 是建立持久局部肿瘤控制的安全有效的策略。接受大剂量大分割 SRS 的患者一年局部进展率低于 5%（95% CI：0-12.2%），优于低剂量大分割 SRS 的结果。单次 SRS 后局部进展率低于 10%（95% CI：0-19.0%）。
Decompression surgery followed by adjuvant radiotherapy is an effective therapy for preservation or recovery of neurologic function and achieving durable local disease control in patients suffering from metastatic epidural spinal cord compression. The authors examine the outcomes of postoperative image-guided intensity-modulated radiation therapy (IG-IMRT) delivered as single-fraction or hypofractionated stereotactic radiosurgery (SRS) for achieving long-term local tumor control. A retrospective chart review identified 186 patients with epidural spinal cord compression from spinal metastases who were treated with surgical decompression, instrumentation, and postoperative radiation delivered as either single-fraction SRS (24 Gy) in 40 patients (22%), high-dose hypofractionated SRS (24-30 Gy in 3 fractions) in 37 patients (20%), or low-dose hypofractionated SRS (18-36 Gy in 5 or 6 fractions) in 109 patients (58%). The relationships between postoperative adjuvant SRS dosing and fractionation, patient characteristics, tumor histology-specific radiosensitivity, grade of epidural spinal cord compression, extent of surgical decompression, response to preoperative radiotherapy, and local tumor control were evaluated by competing risks analysis. The total cumulative incidence of local progression was 16.4% one year after SRS. Multivariate Gray’s competing risks analysis revealed a significant improvement in local control with high-dose hypofractionated SRS (4.1% cumulative incidence of local progression at 1 year; hazard ratio = 0.12, p = 0.04) as compared to low-dose hypofractionated SRS (22.6% local progression at 1 year; HR = 1). Although univariate analysis demonstrated a trend towards greater risk of local progression for patients that failed preoperative cEBRT (22.2% local progression at 1 year, HR = 1.96, p = 0.07) compared to patients who did not receive any preoperative radiotherapy (11.2% local progression at 1 year, HR = 1), this association was not confirmed with multivariate analysis. No other variable significantly correlated with progression-free survival, including radiation sensitivity of tumor histology, grade of epidural spinal cord compression, extent of surgical decompression, or gender. Postoperative adjuvant SRS following epidural spinal cord decompression and instrumentation is a safe and effective strategy for establishing durable local tumor control regardless of tumor histology-specific radiosensitivity. Patients who received high-dose hypofractionated SRS demonstrated one-year local progression rates less than 5% (95% CI: 0-12.2%), which were superior to the results of low-dose hypofractionated SRS. The local progression rate after single-fraction SRS was less than 10% (95% CI: 0-19.0%).