脊柱轉(zhuǎn)移性疾病課件

metastaticspinedisease:EvolutionXUWENBINSIRRUNRUNSHAWHOSPITALmetastaticspinedisease:Evol1backgroundIntheUSA,nearly300000adultshaveosseousmetastaticdisease,withapproximately60%ofthemetastasesbeingspinalmetastases.Approximately10%ofpatientswithspinalmetastasesdevelopspinalcordcompression—asevereandoftenpermanentlydisablingconditionthatisanoncologicalemergency.Historically,spinalmetastaseshavebeentreatedwithinvasivesurgicalapproaches(eg,en-blocresection),orlow-dosepalliativeconventionalexternal-beamradiotherapy(EBRT),orboth.backgroundIntheUSA,nearly32脊柱轉(zhuǎn)移性疾病課件3backgroundEvolutionofsurgerycanbetracedfrominappropriateopensurgery(i.e.laminectomy)toappropriateopen(i.e.posteriorinstrumentationanddecompression)andfurthertominimallyinvasivesurgery.Presently,thebestclinicaloutcomesareachievedbysurgerywithtimelypostoperativeradiotherapy.

spinestereotacticbodyradiotherapy(SBRT),spinestereotacticradiosurgery(SRS)backgroundEvolutionofsurgery4Primarysite乳腺22%肺15%前列腺10%黑色素瘤9%淋巴瘤7%胃腸道5%腎臟6%甲狀腺3%男性：肺癌，前列腺癌，腎癌，肝癌，胃癌。女性：乳腺癌、肺癌、子宮癌、甲狀腺癌、結(jié)腸癌、胃癌。Primarysite乳腺22%男性：肺癌，前列腺癌，腎癌5Lifeexpectancy肺癌：術(shù)后4月結(jié)腸癌：7月腎癌：11.3月前列腺癌：14月乳腺癌：21月肝癌：2年甲狀腺癌：10年（80-95%）1年：48%5年：1.5%Lifeexpectancy肺癌：術(shù)后4月1年：48%6InvolvedsegmentAutopsystudieshavedemonstratedthelumbarspinetobemostcommonlyinvolved,followedbythethoracicandcervicalsegments.Clinically,symptomaticspinalmetastasesaremostoftenlocalizedtothethoracicspine(withspecialpredilectionforthesegmentsaboutT4andT11),followedbythelumbarandcervicalsegments.Thoracic70%Lumbar20%Cervical10%InvolvedsegmentAutopsystudie7metastasispathwayHematogenousmetastasis：Batson’svenousplexus，cancerembolusLymphaticmetastasisImplantationmetastasisCSFmetastasismetastasispathwayHematogenous8Clinicalmanifestation疼痛是最常見的癥狀，約有70%患者以疼痛起病。疼痛常逐漸變?yōu)槌掷m(xù)性加劇，夜間痛明顯，制動多無效。嚴(yán)重者止痛藥無效。大約有50%的胸脊髓損害患者在脊髓壓迫癥狀出現(xiàn)時即表現(xiàn)出神經(jīng)根性疼痛。疼痛因病癥部位不同而異。

由于轉(zhuǎn)移瘤主要位于椎體，往往從前方壓迫椎體束或前角細(xì)胞，故運動功能損害常先出現(xiàn)。與其他脊髓病損類似，括約肌功能損害常提示不良預(yù)后。以脊柱轉(zhuǎn)移為首發(fā)癥狀的為10%。Clinicalmanifestation疼痛是最常見的癥9RadiologicalexamX線平片是脊柱轉(zhuǎn)移瘤診斷最基本的影像學(xué)檢查方法，常表現(xiàn)為骨質(zhì)疏松、溶骨性或硬化性改變，以椎弓根消失（貓頭鷹眨眼征）、椎體塌陷較常見，椎間隙通常正常。博蘭（Boland）等認(rèn)為椎體的扁平壓縮比楔形變更有意義。相比X線平片，核素全身骨掃描可提前3~6個月發(fā)現(xiàn)骨性損害，其靈敏度高達(dá)95%~97%,多表現(xiàn)為放射性濃聚，對可疑骨轉(zhuǎn)移瘤患者應(yīng)盡量作骨掃描檢查。對于椎體破壞及椎旁、椎管內(nèi)占位性病變，應(yīng)用CT檢查顯示較清楚，但當(dāng)病變較小、CT掃描層距較寬時，容易漏診。對于軟組織病變檢查，MRI可提供比X線平片、同位素、CT等檢查更精確的影像學(xué)信息。對于選擇治療方法、手術(shù)進(jìn)路等都具有重要的實用價值。

RadiologicalexamX線平片是脊柱轉(zhuǎn)移瘤診斷10脊柱轉(zhuǎn)移性疾病課件11脊柱轉(zhuǎn)移性疾病課件12questionsGlobalperformancestatus?Lifeexpectancy?Mechanicalstableorunstable?Surgery,radiotherapy,orchemotherapy?Whensurgery?Radiotherapybeforeorafterthesurgery?Howlong?Medicinechoose,Steroidetc?questionsGlobalperformancest13脊柱轉(zhuǎn)移性疾病課件14脊柱轉(zhuǎn)移性疾病課件15KPS評分References:

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SchagCC,HeinrichRL,GanzPA.Karnofskyperformancestatusrevisited:Reliability,validity,andguidelines.JClinOncology.1984;2:187-193.KPS評分References:

Crooks,V,Wa16ToMITa評分Tomita等對67例脊柱轉(zhuǎn)移性腫瘤患者進(jìn)行回顧性分析并總結(jié)制定新的預(yù)后評分系統(tǒng)，根據(jù)腫瘤惡性程度、臟器轉(zhuǎn)移及骨轉(zhuǎn)移情況進(jìn)行評價，總分2~10分，根據(jù)不同評分指導(dǎo)選擇不同治療方案。前瞻性研究顯示其預(yù)期生存時間和實際生存時間符合率為84%。注重預(yù)后，沒有把神經(jīng)壓迫考慮進(jìn)去。

ToMITa評分Tomita等對67例脊柱轉(zhuǎn)移性腫瘤患者進(jìn)行17Tomita評分Tomita評分18修正的Tokuhashi評分提示平均生存時間Zou等研究認(rèn)為，修正的Tokuhashi評分系統(tǒng)對于短期預(yù)后的判斷較為準(zhǔn)確，而Tomita評分系統(tǒng)則更適用于長期預(yù)后結(jié)果的推測。ZouXN,GrejsA,LiHS,etal.Estimationoflifeexpectancyforselectingsurgicalprocedureandpredictingprognosisofextraduralspinalmetastases[J].AiZheng，2006，25(11):1406—1410.修正的Tokuhashi評分提示平均生存時間ZouXN,19脊柱轉(zhuǎn)移性疾病課件20脊柱轉(zhuǎn)移性疾病課件21脊柱轉(zhuǎn)移性疾病課件22SINS系統(tǒng)：穩(wěn)定性評估世界脊柱腫瘤研究小組（GSTSG）對SINS系統(tǒng)進(jìn)行可信度及有效性分析，認(rèn)為其預(yù)測準(zhǔn)確性較好，靈敏度和特異度分別為95.7和79.52%。但SINS系統(tǒng)僅針對病灶局部穩(wěn)定性進(jìn)行評價，并未考慮患者全身情況，僅能用于制定局部治療方案，無法對患者預(yù)后進(jìn)行評估。SINS系統(tǒng)：穩(wěn)定性評估世界脊柱腫瘤研究小組（GSTSG）對23Kostuik六柱理論：穩(wěn)定性Kostuik的六柱理論經(jīng)常用于評價脊柱的穩(wěn)定性。kostuik分脊椎成六柱，包括椎體十字分割的四柱，和后部的兩柱，并提出腫瘤占三柱或更多時會出現(xiàn)脊柱不穩(wěn)，而當(dāng)腫瘤累及五個或更多柱時，脊柱不穩(wěn)更加嚴(yán)重。他還提出，椎體塌陷角為20°或更大時為脊柱不穩(wěn)。這種分類是一種有用的準(zhǔn)則，但也并非適用任何情況，因為有時腫瘤可能侵犯三或更多的部分，而不引起癥狀。1-2部分破壞屬于穩(wěn)定3-4部分破壞相對不穩(wěn)5-6部分破壞絕對不穩(wěn)

Kostuik六柱理論：穩(wěn)定性Kostuik的六柱理論經(jīng)常用24ESCC：Bilsky評分ESCC評分是用來詳細(xì)描述硬膜或脊髓受壓的程度。0級：指病變局限于骨內(nèi)，無椎管內(nèi)受累；1級：硬膜受壓，脊髓未受壓；2級：脊髓受壓但仍可見腦脊液信號(MRI軸位T2加權(quán)圖像)；3級：脊髓受壓并且腦脊液信號中斷。ESCC：Bilsky評分ESCC評分是用來詳細(xì)描述硬膜或脊25ESCC：Bilsky評分ESCC：Bilsky評分26OncologicalparametersOncologicalparameters27脊柱轉(zhuǎn)移性疾病課件28其他常見評分體系及分類Tomita評分（2009年）：基于預(yù)后分析改良Tokuhashi評分（2005年），Karnofsky評分Harrington評分：基于脊柱穩(wěn)定性及神經(jīng)功能脊柱腫瘤不穩(wěn)定評分（SINS）Weinstein-Boriani-Biagini(WBB)分期：基于局部解剖結(jié)構(gòu)Enneking分期Tomita分型其他常見評分體系及分類Tomita評分（2009年）：基于預(yù)29Harrington評分Harrington評分30Harrington評分Harrington早于1986年就根據(jù)脊柱穩(wěn)定性破壞程度和神經(jīng)功能狀況對脊柱轉(zhuǎn)移性腫瘤進(jìn)行分類。哈林頓認(rèn)為，1，2和3期應(yīng)進(jìn)行保守治療，4或5期需要手術(shù)干預(yù)。3期的患者當(dāng)神經(jīng)系統(tǒng)可能進(jìn)一步退化或癱瘓無改善的情況下，有時需接受手術(shù)治療。因此，骨受累是評估手術(shù)指征的一個重要因素。該分類過于強調(diào)內(nèi)科治療的作用，對于放、化療不敏感腫瘤，外科治療的重要性并未突出，且分類過于簡單，同一類別的患者預(yù)后可能存在極大差異，缺少臨床指導(dǎo)意義，因此目前已很少使用。Harrington評分Harrington早于1986年就31Tomita分型根據(jù)腫瘤侵襲范圍對脊柱轉(zhuǎn)移性腫瘤進(jìn)行分類，以指導(dǎo)手術(shù)方案選擇。1-3型廣泛切除或至少邊緣切除，4-6型只有病灶周圍存在纖維反應(yīng)帶時才能邊緣切除。全脊柱整塊切除手術(shù)適用于2-5型，1、6相對適應(yīng)癥，7禁忌癥。

Tomita分型根據(jù)腫瘤侵襲范圍對脊柱轉(zhuǎn)移性腫瘤進(jìn)行分類，32WBB分期1997年意大利的Boriani等人提出了胸腰椎的WBB脊柱腫瘤外科分期最初針對脊柱原發(fā)性腫瘤而創(chuàng)立，但目前亦應(yīng)用于脊柱轉(zhuǎn)移性腫瘤。該分期以脊髓為中心，按類似鐘表表盤布局將椎體橫斷面分為12區(qū)，并根據(jù)解剖層次以硬膜囊及骨結(jié)構(gòu)為邊界將椎體及椎旁組織分為A~E層。WBB分期可清晰地顯示腫瘤侵襲范圍及脊髓壓迫程度，為手術(shù)方案制定提供重要依據(jù)。WBB分期1997年意大利的Boriani等人提出了胸腰椎的33Radiotherapy

Theprincipaltreatmentofpatientswithspinalmetastasesisradiotherapy.Thetwoprimaryreasonsthatradiotherapyisgiventopatientswithspinalmetastasesarepaincontrolanddurablelocalcontroltoimproveorpreventneurologicalcompromise.Dependingontheintentoftreatmentandothercase-specificcircumstances,radiotherapycanbedeliveredasconventionalEBRT,spineSRS,orSBRT.SpinalmetastasesaremostoftentreatedwithconventionalEBRT.TheprimarygoalofconventionalEBRTistoalleviatepain,andapproximately60–70%ofpatientshaveapartialorcompleteresponsewiththistechnique.AfterconventionalEBRT,about25%ofpatientsreportcompleteresolutioninpain,typicallyforadurationof3–4months,dependingonhistology.RadiotherapyTheprincipaltre34SBRTvsEBRTSBRTvsEBRT35surgeryThegoalofsurgeryistostabilizeamechanicallyunstablespine,decompressspinalcordcompression,removeepiduraldiseasetoallowspineSRSandSBRTtreatment,establishahistologicaldiagnosis,andtoprovidelocalcontrolwhenradiotherapycannotbesafelydelivered.Surgeryalonewillnoteradicatethediseasewithdurablelocalcontrol.Inoneneurosurgicalcaseseries,thelocalrecurrenceratewas96%at4yearsandtherewasnodifferenceinoverallsurvivalbetweenthosewhoreceivedcompleteversusincompletesurgicalresections.TheintegrationofspineSRSintothestandardtreatmentprocessrepresentsaparadigmshiftfromtheyearswhenextensivesurgeriesforgross-totalresectionswereperformedinanattempttocurepatientsofmetastaticdisease.Wedonotrecommenden-blocresectionsinthepalliationofpatientswithspinalmetastases.surgeryThegoalofsurgeryis36surgeryStabilizationwithoutdecompressioncanbeaccomplishedwithexternalbracingorminimallyinvasiveapproaches,suchaspercutaneouscementaugmentationorpercutaneouspediclescrewfixation.Theseprocedureslimittheinterruptionofsystemictherapyandallowforthedeliveryofearlyradiotherapy.surgeryStabilizationwithoutd37surgeryDebulkingEnblocPalliativedecopressionsurgeryDebulki38separationsurgeryThetermseparationsurgerywascoinedbyLilyanaAngelovandEdwardBenzelatTheClevelandClinic,OH,USA,todesignateaprocedureinwhichtumourresectionislimitedtodecompressionofthespinalcordtocreateagaptothetumourandprovideasafetargetforspineSRS.Suchatechniquehelpstofacilitatethedeliveryofanablativedosetotheresidualtumourwhilesparingthespinalcordorcaudaequina.LauferI,RubinDG,LisE,etal.TheNOMSframework:approachtothetreatmentofspinalmetastatictumors.Oncologist2013;18:744–51.LauferI,lorgulescuJB,chapmanT,etal.Localdiseasecontrolforspinalmetastasesfollowing“separationsurgery”andadjuvanthypofractionatedorhigh-dozesingle-fractionstereotacticradiosurgery:outcomeanalysisin186patients.JournalofneurosurgerySpine,2013,;18(3):207-14.separationsurgeryThetermsep39脊柱轉(zhuǎn)移性疾病課件40separationsurgeryTheessentialelementsofmostseparationsurgeriesincludeposterolateraldecompressionviaalaminectomyandpedicleresection,withapartialcorpectomyoftheaffectedlevel.Thissurgerywilldestabilisethespine;thus,astabilisationprocedureisalwaysrequiredinconjunctionwiththetumourresection.DonnellyDJ,Abd-El-BarrMM,LuY.Minimallyinvasivemusclesparingposterior-onlyapproachforlumbarcircumferentialdecompressionandstabilizationtotreatspinemetastasis—technicalreport.WorldNeurosurg2015;84:1484–90.separationsurgeryTheessentia41脊柱轉(zhuǎn)移性疾病課件42NeurointerventionalproceduresCT-guidedbiopsySpinalmyelography(commonlyusedinpatientswhohavecontraindicationstoundergoingMRIofthespine)Localablativetechniques(mostcommonlyusedasasalvagetreatmentoptionincaseswherepreviousradiotherapyhasbeendeliveredandre-irradiationisunlikelytobesafeoreffective)Cementordeviceaugmentationofthespinalcolumn(Thecementused(ie,polymethylmethacrylate)createsanexothermicreactionthatdestroystumourandnerveendingswithina3-mmradiusofthecement)Intra-arterialtumourembolisation(Preoperativetransarterialembolisationofahyper-vascularvertebraltumourwithparticles,glue,orethylenevinylalcoholcanreduceintraoperativebloodloss)WallaceAN,RobinsonCG,MeyerJ,etal.TheMetastaticSpineDiseaseMultidisciplinaryWorkingGroupalgorithms.Oncologist2015;20:1205–15.Neurointerventionalprocedures43CancerrehabilitationmanagementRehabilitationinterventionscanprovidesubstantialpainreliefandimprovestabilisationofthespinewithlessinvasivenessandinherentrisktothepatientthansurgeryorradiotherapy.Forpatientswithanunstableorpotentiallyunstablespine,surgeryisoftenwarranted.However,forpatientswhohavecontraindicationstosafelyundergosurgery,orpatientswhowishtoavoidasurgicalintervention,rehabilitationprovidestwomainoptionsforspinalstabilisation:bracingandmuscularstrengthening.Foradetaileddiscussionoftheinterventionsarehabilitationteamcanprovide,werecommendRajandLofton’sreview.RajVS,LoftonL.Rehabilitationandtreatmentofspinalcordtumors.JSpinalCordMed2013;36:4–11.Cancerrehabilitationmanageme44medicationPainmedicationsareusuallyprescribedinaladderapproach:Startingwithnon-opioidagents(ie,non-steroidalanti-inflammatorydrugsandparacetamol).Formild-to-moderatebreakthroughpain,opioidssuchascodeineandtramadolarerecommended.Forseverebreakthroughpain,opioidssuchasmorphine,oxycodone,hydromorphone,andtransdermalfentanylshouldbestarted,slowlytitrated,androtatedtoensureadequateanalgesia,whileminimisingtheriskforoverdose.Adjuvantsareaddeddependingonthetypeofpain;forexample,gabapentinorpregabalinforneuropathicpain,steroidsforinflammatorypain,andbisphosphonatesforbonepain.WHO.Cancerpainrelief:withaguidetoopioidavailability.Geneva,Switzerland,1996./iris/bitstream/10665/37896/1/9241544821.pdf(accessedFeb1,2017).medicationPainmedicationsare45Take

homemessageLifeexpectancy>2months,KPSscore>40Tomitascore,reversedTokuhashiscoreSINSsystemThegoalofsurgery:tostabilizeamechanicallyunstablespine,decompressspinalcordcompressionSeparationsurgery+SRSMDTTakehomemessageLifeexpectan46常見評分體系

的參考文獻(xiàn)常見評分體系

的參考文獻(xiàn)47Thankyou

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homemessage局部叩擊痛、夜間痛、家族史，既往史，應(yīng)警惕脊柱轉(zhuǎn)移性腫瘤可能目前一般認(rèn)為患者生存期>6周才有可能從穩(wěn)定手術(shù)中獲益，生存期>6個月的患者才考慮行脊柱腫瘤切除術(shù)。伴有背痛的MBD患者可能即將會發(fā)生MSCC而緩慢進(jìn)展的癱瘓，數(shù)小時內(nèi)發(fā)生的完全癱瘓和只有骨塊壓迫的MSCC患者是最有可能從手術(shù)中獲益的人群。（肖建如）如果脊柱是穩(wěn)定的(SINS0-6分)，脊柱腫瘤沒有引起神經(jīng)受壓，多學(xué)科協(xié)作討論后，根據(jù)腫瘤具體類型(例如乳腺癌、前列腺癌等放化療敏感的腫瘤)可以先行放療或化療，以控制或減緩腫瘤進(jìn)展。脊柱轉(zhuǎn)移性腫瘤的診斷也須遵循臨床、影像和病理三結(jié)合的原則。Takehomemessage局部叩擊痛、夜間痛、家族史49Take

homemessage對于偶然發(fā)現(xiàn)、無明顯癥狀的孤立性脊柱轉(zhuǎn)移瘤，應(yīng)先行放療，如腫瘤增長較快，預(yù)計短期會發(fā)生病理骨折者，為避免脊髓在病理骨折時發(fā)生嚴(yán)重?fù)p傷，多建議手術(shù)治療。多發(fā)脊柱轉(zhuǎn)移瘤并非手術(shù)禁忌，筆者的經(jīng)驗是對引起神經(jīng)癥狀的轉(zhuǎn)移灶進(jìn)行外科干預(yù)可取得較好的療效。目前認(rèn)為患者完全癱瘓大于48h術(shù)后恢復(fù)神經(jīng)功能的可能性較低，是手術(shù)的相對禁忌證。預(yù)期生存期小于3個月的患者無法從手術(shù)中獲益，是手術(shù)的禁忌證。術(shù)前放射治療增加手術(shù)傷口不愈合的風(fēng)險，而且這種風(fēng)險與術(shù)前放療的劑量和頻次無關(guān),已不再提倡。開放性手術(shù)一般于術(shù)后2~3周待傷口愈合后再進(jìn)行放射治療，而對于微創(chuàng)手術(shù)術(shù)后患者可立即接受放療。Takehomemessage對于偶然發(fā)現(xiàn)、無明顯癥狀的50metastaticspinedisease:EvolutionXUWENBINSIRRUNRUNSHAWHOSPITALmetastaticspinedisease:Evol51backgroundIntheUSA,nearly300000adultshaveosseousmetastaticdisease,withapproximately60%ofthemetastasesbeingspinalmetastases.Approximately10%ofpatientswithspinalmetastasesdevelopspinalcordcompression—asevereandoftenpermanentlydisablingconditionthatisanoncologicalemergency.Historically,spinalmetastaseshavebeentreatedwithinvasivesurgicalapproaches(eg,en-blocresection),orlow-dosepalliativeconventionalexternal-beamradiotherapy(EBRT),orboth.backgroundIntheUSA,nearly352脊柱轉(zhuǎn)移性疾病課件53backgroundEvolutionofsurgerycanbetracedfrominappropriateopensurgery(i.e.laminectomy)toappropriateopen(i.e.posteriorinstrumentationanddecompression)andfurthertominimallyinvasivesurgery.Presently,thebestclinicaloutcomesareachievedbysurgerywithtimelypostoperativeradiotherapy.

spinestereotacticbodyradiotherapy(SBRT),spinestereotacticradiosurgery(SRS)backgroundEvolutionofsurgery54Primarysite乳腺22%肺15%前列腺10%黑色素瘤9%淋巴瘤7%胃腸道5%腎臟6%甲狀腺3%男性：肺癌，前列腺癌，腎癌，肝癌，胃癌。女性：乳腺癌、肺癌、子宮癌、甲狀腺癌、結(jié)腸癌、胃癌。Primarysite乳腺22%男性：肺癌，前列腺癌，腎癌55Lifeexpectancy肺癌：術(shù)后4月結(jié)腸癌：7月腎癌：11.3月前列腺癌：14月乳腺癌：21月肝癌：2年甲狀腺癌：10年（80-95%）1年：48%5年：1.5%Lifeexpectancy肺癌：術(shù)后4月1年：48%56InvolvedsegmentAutopsystudieshavedemonstratedthelumbarspinetobemostcommonlyinvolved,followedbythethoracicandcervicalsegments.Clinically,symptomaticspinalmetastasesaremostoftenlocalizedtothethoracicspine(withspecialpredilectionforthesegmentsaboutT4andT11),followedbythelumbarandcervicalsegments.Thoracic70%Lumbar20%Cervical10%InvolvedsegmentAutopsystudie57metastasispathwayHematogenousmetastasis：Batson’svenousplexus，cancerembolusLymphaticmetastasisImplantationmetastasisCSFmetastasismetastasispathwayHematogenous58Clinicalmanifestation疼痛是最常見的癥狀，約有70%患者以疼痛起病。疼痛常逐漸變?yōu)槌掷m(xù)性加劇，夜間痛明顯，制動多無效。嚴(yán)重者止痛藥無效。大約有50%的胸脊髓損害患者在脊髓壓迫癥狀出現(xiàn)時即表現(xiàn)出神經(jīng)根性疼痛。疼痛因病癥部位不同而異。

由于轉(zhuǎn)移瘤主要位于椎體，往往從前方壓迫椎體束或前角細(xì)胞，故運動功能損害常先出現(xiàn)。與其他脊髓病損類似，括約肌功能損害常提示不良預(yù)后。以脊柱轉(zhuǎn)移為首發(fā)癥狀的為10%。Clinicalmanifestation疼痛是最常見的癥59RadiologicalexamX線平片是脊柱轉(zhuǎn)移瘤診斷最基本的影像學(xué)檢查方法，常表現(xiàn)為骨質(zhì)疏松、溶骨性或硬化性改變，以椎弓根消失（貓頭鷹眨眼征）、椎體塌陷較常見，椎間隙通常正常。博蘭（Boland）等認(rèn)為椎體的扁平壓縮比楔形變更有意義。相比X線平片，核素全身骨掃描可提前3~6個月發(fā)現(xiàn)骨性損害，其靈敏度高達(dá)95%~97%,多表現(xiàn)為放射性濃聚，對可疑骨轉(zhuǎn)移瘤患者應(yīng)盡量作骨掃描檢查。對于椎體破壞及椎旁、椎管內(nèi)占位性病變，應(yīng)用CT檢查顯示較清楚，但當(dāng)病變較小、CT掃描層距較寬時，容易漏診。對于軟組織病變檢查，MRI可提供比X線平片、同位素、CT等檢查更精確的影像學(xué)信息。對于選擇治療方法、手術(shù)進(jìn)路等都具有重要的實用價值。

RadiologicalexamX線平片是脊柱轉(zhuǎn)移瘤診斷60脊柱轉(zhuǎn)移性疾病課件61脊柱轉(zhuǎn)移性疾病課件62questionsGlobalperformancestatus?Lifeexpectancy?Mechanicalstableorunstable?Surgery,radiotherapy,orchemotherapy?Whensurgery?Radiotherapybeforeorafterthesurgery?Howlong?Medicinechoose,Steroidetc?questionsGlobalperformancest63脊柱轉(zhuǎn)移性疾病課件64脊柱轉(zhuǎn)移性疾病課件65KPS評分References:

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HollenPJ,GrallaRJ,etal.Measurementofqualityoflifeinpatientswithlungcancerinmulticentertrialsofnewtherapies.Cancer.1994;73:2087-2098.

O'TooleDM,GoldenAM.Evaluatingcancerpatientsforrehabilitationpotential.WestJMed.1991;155:384-387.

OxfordTextbookofPalliativeMedicine,OxfordUniversityPress.1993;109.

SchagCC,HeinrichRL,GanzPA.Karnofskyperformancestatusrevisited:Reliability,validity,andguidelines.JClinOncology.1984;2:187-193.KPS評分References:

Crooks,V,Wa66ToMITa評分Tomita等對67例脊柱轉(zhuǎn)移性腫瘤患者進(jìn)行回顧性分析并總結(jié)制定新的預(yù)后評分系統(tǒng)，根據(jù)腫瘤惡性程度、臟器轉(zhuǎn)移及骨轉(zhuǎn)移情況進(jìn)行評價，總分2~10分，根據(jù)不同評分指導(dǎo)選擇不同治療方案。前瞻性研究顯示其預(yù)期生存時間和實際生存時間符合率為84%。注重預(yù)后，沒有把神經(jīng)壓迫考慮進(jìn)去。

ToMITa評分Tomita等對67例脊柱轉(zhuǎn)移性腫瘤患者進(jìn)行67Tomita評分Tomita評分68修正的Tokuhashi評分提示平均生存時間Zou等研究認(rèn)為，修正的Tokuhashi評分系統(tǒng)對于短期預(yù)后的判斷較為準(zhǔn)確，而Tomita評分系統(tǒng)則更適用于長期預(yù)后結(jié)果的推測。ZouXN,GrejsA,LiHS,etal.Estimationoflifeexpectancyforselectingsurgicalprocedureandpredictingprognosisofextraduralspinalmetastases[J].AiZheng，2006，25(11):1406—1410.修正的Tokuhashi評分提示平均生存時間ZouXN,69脊柱轉(zhuǎn)移性疾病課件70脊柱轉(zhuǎn)移性疾病課件71脊柱轉(zhuǎn)移性疾病課件72SINS系統(tǒng)：穩(wěn)定性評估世界脊柱腫瘤研究小組（GSTSG）對SINS系統(tǒng)進(jìn)行可信度及有效性分析，認(rèn)為其預(yù)測準(zhǔn)確性較好，靈敏度和特異度分別為95.7和79.52%。但SINS系統(tǒng)僅針對病灶局部穩(wěn)定性進(jìn)行評價，并未考慮患者全身情況，僅能用于制定局部治療方案，無法對患者預(yù)后進(jìn)行評估。SINS系統(tǒng)：穩(wěn)定性評估世界脊柱腫瘤研究小組（GSTSG）對73Kostuik六柱理論：穩(wěn)定性Kostuik的六柱理論經(jīng)常用于評價脊柱的穩(wěn)定性。kostuik分脊椎成六柱，包括椎體十字分割的四柱，和后部的兩柱，并提出腫瘤占三柱或更多時會出現(xiàn)脊柱不穩(wěn)，而當(dāng)腫瘤累及五個或更多柱時，脊柱不穩(wěn)更加嚴(yán)重。他還提出，椎體塌陷角為20°或更大時為脊柱不穩(wěn)。這種分類是一種有用的準(zhǔn)則，但也并非適用任何情況，因為有時腫瘤可能侵犯三或更多的部分，而不引起癥狀。1-2部分破壞屬于穩(wěn)定3-4部分破壞相對不穩(wěn)5-6部分破壞絕對不穩(wěn)

Kostuik六柱理論：穩(wěn)定性Kostuik的六柱理論經(jīng)常用74ESCC：Bilsky評分ESCC評分是用來詳細(xì)描述硬膜或脊髓受壓的程度。0級：指病變局限于骨內(nèi)，無椎管內(nèi)受累；1級：硬膜受壓，脊髓未受壓；2級：脊髓受壓但仍可見腦脊液信號(MRI軸位T2加權(quán)圖像)；3級：脊髓受壓并且腦脊液信號中斷。ESCC：Bilsky評分ESCC評分是用來詳細(xì)描述硬膜或脊75ESCC：Bilsky評分ESCC：Bilsky評分76OncologicalparametersOncologicalparameters77脊柱轉(zhuǎn)移性疾病課件78其他常見評分體系及分類Tomita評分（2009年）：基于預(yù)后分析改良Tokuhashi評分（2005年），Karnofsky評分Harrington評分：基于脊柱穩(wěn)定性及神經(jīng)功能脊柱腫瘤不穩(wěn)定評分（SINS）Weinstein-Boriani-Biagini(WBB)分期：基于局部解剖結(jié)構(gòu)Enneking分期Tomita分型其他常見評分體系及分類Tomita評分（2009年）：基于預(yù)79Harrington評分Harrington評分80Harrington評分Harrington早于1986年就根據(jù)脊柱穩(wěn)定性破壞程度和神經(jīng)功能狀況對脊柱轉(zhuǎn)移性腫瘤進(jìn)行分類。哈林頓認(rèn)為，1，2和3期應(yīng)進(jìn)行保守治療，4或5期需要手術(shù)干預(yù)。3期的患者當(dāng)神經(jīng)系統(tǒng)可能進(jìn)一步退化或癱瘓無改善的情況下，有時需接受手術(shù)治療。因此，骨受累是評估手術(shù)指征的一個重要因素。該分類過于強調(diào)內(nèi)科治療的作用，對于放、化療不敏感腫瘤，外科治療的重要性并未突出，且分類過于簡單，同一類別的患者預(yù)后可能存在極大差異，缺少臨床指導(dǎo)意義，因此目前已很少使用。Harrington評分Harrington早于1986年就81Tomita分型根據(jù)腫瘤侵襲范圍對脊柱轉(zhuǎn)移性腫瘤進(jìn)行分類，以指導(dǎo)手術(shù)方案選擇。1-3型廣泛切除或至少邊緣切除，4-6型只有病灶周圍存在纖維反應(yīng)帶時才能邊緣切除。全脊柱整塊切除手術(shù)適用于2-5型，1、6相對適應(yīng)癥，7禁忌癥。

Tomita分型根據(jù)腫瘤侵襲范圍對脊柱轉(zhuǎn)移性腫瘤進(jìn)行分類，82WBB分期1997年意大利的Boriani等人提出了胸腰椎的WBB脊柱腫瘤外科分期最初針對脊柱原發(fā)性腫瘤而創(chuàng)立，但目前亦應(yīng)用于脊柱轉(zhuǎn)移性腫瘤。該分期以脊髓為中心，按類似鐘表表盤布局將椎體橫斷面分為12區(qū)，并根據(jù)解剖層次以硬膜囊及骨結(jié)構(gòu)為邊界將椎體及椎旁組織分為A~E層。WBB分期可清晰地顯示腫瘤侵襲范圍及脊髓壓迫程度，為手術(shù)方案制定提供重要依據(jù)。WBB分期1997年意大利的Boriani等人提出了胸腰椎的83Radiotherapy

Theprincipaltreatmentofpatientswithspinalmetastasesisradiotherapy.Thetwoprimaryreasonsthatradiotherapyisgiventopatientswithspinalmetastasesarepaincontrolanddurablelocalcontroltoimproveorpreventneurologicalcompromise.Dependingontheintentoftreatmentandothercase-specificcircumstances,radiotherapycanbedeliveredasconventionalEBRT,spineSRS,orSBRT.SpinalmetastasesaremostoftentreatedwithconventionalEBRT.TheprimarygoalofconventionalEBRTistoalleviatepain,andapproximately60–70%ofpatientshaveapartialorcompleteresponsewiththistechnique.AfterconventionalEBRT,about25%ofpatientsreportcompleteresolutioninpain,typicallyforadurationof3–4months,dependingonhistology.RadiotherapyTheprincipaltre84SBRTvsEBRTSBRTvsEBRT85surgeryThegoalofsurgeryistostabilizeamechanicallyunstablespine,decompressspinalcordcompression,removeepiduraldiseasetoallowspineSRSandSBRTtreatment,establishahistologicaldiagnosis,andtoprovidelocalcontrolwhenradiotherapycannotbesafelydelivered.Surgeryalonewillnoteradicatethediseasewithdurablelocalcontrol.Inoneneurosurgicalcaseseries,thelocalrecurrenceratewas96%at4yearsandtherewasnodifferenceinoverallsurvivalbetweenthosewhoreceivedcompleteversusincompletesurgicalresections.TheintegrationofspineSRSintothestandardtreatmentprocessrepresentsaparadigmshiftfromtheyearswhenextensivesurgeriesforgross-totalresectionswereperformedinanattempttocurepatientsofmetastaticdisease.Wedonotrecommenden-blocresectionsinthepalliationofpatientswithspinalmetastases.surgeryThegoalofsurgeryis86surgeryStabilizationwithoutdecompressioncanbeaccomplishedwithexternalbracingorminimallyinvasiveapproaches,suchaspercutaneouscementaugmentationorpercutaneouspediclescrewfixation.Theseprocedureslimittheinterruptionofsystemictherapyandallowforthedeliveryofearlyradiotherapy.surgeryStabilizationwithoutd87surgeryDebulkingEnblocPalliativedecopressionsurgeryDebulki88separationsurgeryThetermseparationsurgerywascoinedbyLilyanaAngelovandEdwardBenzelatTheClevelandClinic,OH,USA,todesignateaprocedureinwhichtumourresectionislimitedtodecompressionofthespinalcordtocreateagaptothetumourandprovideasafetargetforspineSRS.Suchatechniquehelpstofacilitatethedeliveryofanablativedosetotheresidualtumourwhilesparingthespinalcordorcaudaequina.LauferI,RubinDG,LisE,etal.TheNOMSframework:approachtothetreatmentofspinalmetastatictumors.Oncologist2013;18:744–51.LauferI,lorgulescuJB,chapmanT,etal.Localdiseasecontrolforspinalmetastasesfollowing“separationsurgery”andadjuvanthypofractionatedorhigh-dozesingle-fractionstereotacticradiosurgery:outcomeanalysisin186patients.JournalofneurosurgerySpine,2013,;18(3):207-14.separationsurgeryThetermsep89脊柱轉(zhuǎn)移性疾病課件90separationsurgeryTheessentialelementsofmostseparationsurgeriesincludeposterolateraldecompressionviaalaminectomyandpedicleresection,withapartialcorpectomyoftheaffectedlevel.Thissurgerywilldestabilisethespine;thus,astabilisationprocedureisalwaysrequiredinconjunctionwiththetumourresection.DonnellyDJ,Abd-El-BarrMM,LuY.Minimallyinvasivemusclesparingposterior-onlyapproachforlumbarcircumferentialdecompressionandstabilizationtotreatspinemetastasis—technicalreport.WorldNeurosurg2015;84:1484–90.separationsurgeryTheessentia91脊柱轉(zhuǎn)移性疾病課件92NeurointerventionalproceduresCT-guidedbiopsySpinalmyelography(commonlyusedinpatientswhohavecontraindicationstoundergoingMRIofthespine)Localablativetechniques(mostcommonlyusedasasalvagetreatmentoptionincaseswherepreviousradiotherapyhasbeendeliveredandre-irradiationisunlikelytobesafeoreffective)Cementordeviceaugmentationofthespinalcolumn(Thecementused(ie,polymethylmethacrylate)createsanexothermicreactionthatdestroystumourandnerveendingswithina3-mmradiusofthecement)Intra-arterialtumourembolisation(Preoperativetransarterialembolisationofahyper-vascularvertebraltumourwithparticles,glue,orethylenevinylalcoholcanreduceintraoperativebloodloss)WallaceAN,RobinsonCG,MeyerJ,etal.TheMetastaticSpineDiseaseMultidisciplinaryWorkingGroupalgorithms.Oncologist2015;20:1205–15.Neurointerventionalprocedures93CancerrehabilitationmanagementRehabilitationinterventio