Paradigmenwechsel in der Tumorchirurgie der Wirbelsäule – von der Radiofrequenzablation und Kypho-IORT zu Separation Surgery und MIS-Instrumentation. Wo stehen wir? Therapiealgorithmus und Evidenz

Zusammenfassung

Die deutliche Mehrheit aller spinalen Tumore stellen die spinalen Metastasen (ca. 90%) dar. Bekanntermaßen finden sich hier überwiegend Absiedlungen von Adenokarzinomen der Mamma, der Prostata, der Lunge und des gastrointestinalen Trakts. Dank zielgerichteter und neuartiger Therapien nicht nur dieser Entitäten, zeigt sich das Überleben in den letzten Jahren deutlich verbessert. Die Entscheidungskriterien zur operativen Therapieplanung bilden der neurologische Status des Patienten, die onkologischen Eigenschaften der Metastase, die mechanische Stabilität der metastasierten Wirbelsäule und der Fortschritt der systemischen Krebserkrankung sowie der Komorbiditäten des Patienten, ausgedrückt als Karnofski Performance Index (KPI) oder des Eastern Cooperative Oncology Group. Aus diesem Gesamtbild kann ein Therapiealgorithmus basierend auf etablierten Scores festgelegt werden, der zur Entscheidungsfindung herangezogen werden kann und unten aufgeführt ist.

Die Schmerztherapie bildet dabei die Hauptsäule in der Therapie von Patienten mit spinalen Metastasen. Eine weitere Säule ist die lokale Tumorkontrolle welche durch stereotaktische Bestrahlung, „stereotactic body radiotherapy“ (SBRT) , oder durch stereotaktische Radiochirurgie, „stereotactic radiosurgery“ (SRS), wesentlich verbessert werden kann. Sind Metastasen auf den Wirbelkörper begrenzt und Schmerz- sowie lokale Tumorkontrolle das Therapieziel, so ist eine kombinierte perkutane Intervention basierend auf der Zementaugmentation und intra-operativer Bestrahlung zu erwägen.

Die Implementation der MIS-Instrumentation, gefolgt von spinaler SRS/SBRT in die Tumorchirurgie der Wirbelsäule, scheint bei Metastasen mit Rückenmarkskompression eine sinnvolle und wahrscheinlich überlegene Alternative zu den bisherigen Eingriffen und Operationsmethoden darzustellen. Die steigende Komplexität der Entscheidungsfindung und Therapie von Patienten mit Wirbelsäulenmetastasen sollte in Zentren mit ausreichender Expertise, Fallzahlen und angeschlossener Strahlentherapie mit der Möglichkeit einer SBRT/SRS am besten im Rahmen einer Tumorkonferenz erfolgen.

Abstract

Primary spinal tumors are a rare entity, the diagnostic and therapy options have been readily discussed and shall not be topic in this overview [1] [2]. Mostly spinal tumors are made up of spinal metastases of other primary tumors (ca. 90%). Mainly these metastases originate from adenocarcinomas of the breast, the prostate, the lungs or the gastrointestinal tract. Surgical, radiotherapeutic („stereotactic body radiotherapy“ (SBRT) or stereotactic radio surgery (SRS), pharmaceutical and oncological advancements such as targeted therapy and newly developed therapeutic concepts are constantly improving the survival rate for these cancer patients. In spinal surgery the main pillars in decision making are neurologic status of the patient, oncology of the tumor/metastases, mechanical stability of the spine, systemic disease status and co-morbidities which can be summoned up within the Karnofski Performance Index (KPI) or the Eastern Cooperative Oncology Group (ECOG) . Using scoring systems or algorithms can be useful and we will present such an algorithm in this publication. SBRT or SRS are major contributors to local tumor control. Pain management continues to be a top issue for patients suffering from spinal metastases. Recent literature suggests we could be on the doorstep of a change of paradigm towards MIS Instrumentation followed by SRS/SBRT.

In spinal metastases confined to the vertebral body without instability percutaneous interventions should be considered, especially for their excellent effect in reducing pain. Implementation of MISS (minimally-invasive spinal surgery) instrumentation followed by spinal SRS (separation surgery), i.e. hybrid surgery (Barzilai et al., 2019) as a viable treatment option for spinal tumors with spinal cord compression has shown promising results as opposed to open surgery. Treatment of patients with spinal metastases should be performed in specialized centers with sufficient case numbers and the infrastructure for postoperative SBRT/SRS. To further evaluate MIS instrumentation in spinal tumor surgery more RCTs (randomized control trials) are needed.

Schlüsselwörter

Tumorchirurgie der Wirbelsäule - stereotaktische Radiotherapie - minimalinvasive spinale Operation - spinale Metastasen

Keywords

minimally-invasive spinal surgery (MISS) - hybrid surgery - stereotactic radiosurgery (SRS) - stereotactic body radiation therapy (SBRT) - separation surgery - surgery of spinal tumors - spinal metastases

Publication History

Article published online:
24 August 2023

• Literatur

• 1 Kumar N, Tan WLB, Wei W. et al. An overview of the tumors affecting the spine-inside to out. Neurooncol Pract 2020; 7: i10-i17 DOI: 10.1093/nop/npaa049.
• 2 Ciftdemir M, Kaya M, Selcuk E. et al. Tumors of the spine. World J Orthop 2016; 7: 109-116 DOI: 10.5312/wjo.v7.i2.109.
• 3 Laufer I, Rubin DG, Lis E. et al. The NOMS framework: approach to the treatment of spinal metastatic tumors. Oncologist 2013; 18: 744-751 DOI: 10.1634/theoncologist.2012-0293.
• 4 Conti A, Acker G, Kluge A. et al. Decision Making in Patients With Metastatic Spine. The Role of Minimally Invasive Treatment Modalities. Front Oncol 2019; 9: 915 DOI: 10.3389/fonc.2019.00915.
• 5 Bartels RH, van der Linden YM, van der Graaf WT. Spinal extradural metastasis: review of current treatment options. CA Cancer J Clin 2008; 58: 245-259 DOI: 10.3322/CA.2007.0016.
• 6 Bilsky MH, Laufer I, Fourney DR. et al. Reliability analysis of the epidural spinal cord compression scale. J Neurosurg Spine 2010; 13: 324-328 DOI: 10.3171/2010.3.SPINE09459.
• 7 Nater A, Martin AR, Sahgal A. et al. Symptomatic spinal metastasis: A systematic literature review of the preoperative prognostic factors for survival, neurological, functional and quality of life in surgically treated patients and methodological recommendations for prognostic studies. PLoS One 2017; 12: e0171507 DOI: 10.1371/journal.pone.0171507.
• 8 Patil CG, Lad SP, Santarelli J. et al. National inpatient complications and outcomes after surgery for spinal metastasis from 1993–2002. Cancer 2007; 110: 625-630 DOI: 10.1002/cncr.22819.
• 9 Schoenfeld AJ, Le HV, Marjoua Y. et al. Assessing the utility of a clinical prediction score regarding 30-day morbidity and mortality following metastatic spinal surgery: the New England Spinal Metastasis Score (NESMS). Spine J 2016; 16: 482-490 DOI: 10.1016/j.spinee.2015.09.043.
• 10 Berenson J, Pflugmacher R, Jarzem P. et al. Balloon kyphoplasty versus non-surgical fracture management for treatment of painful vertebral body compression fractures in patients with cancer: a multicentre, randomised controlled trial. Lancet Oncol 2011; 12: 225-235 DOI: 10.1016/S1470-2045(11)70008-0.
• 11 Galibert P, Deramond H, Rosat P. et al. Preliminary note on the treatment of vertebral angioma by percutaneous acrylic vertebroplasty. Neurochirurgie 1987; 33: 166-168
• 12 Mohme M, Riethdorf S, Dreimann M. et al. Circulating Tumour Cell Release after Cement Augmentation of Vertebral Metastases. Sci Rep 2017; 7: 7196 DOI: 10.1038/s41598-017-07649-z.
• 13 Cheung P. Stereotactic body radiotherapy for oligoprogressive cancer. Br J Radiol 2016; 89: 20160251 DOI: 10.1259/bjr.20160251.
• 14 Rades D, Stalpers LJ, Veninga T. et al. Evaluation of five radiation schedules and prognostic factors for metastatic spinal cord compression. J Clin Oncol 2005; 23: 3366-3375 DOI: 10.1200/JCO.2005.04.754.
• 15 Chen F, Xia YH, Cao WZ. et al. Percutaneous kyphoplasty for the treatment of spinal metastases. Oncol Lett 2016; 11: 1799-1806 DOI: 10.3892/ol.2016.4121.
• 16 Murali N, Turmezei T, Bhatti S. et al. What is the effectiveness of radiofrequency ablation in the management of patients with spinal metastases? A systematic review and meta-analysis. J Orthop Surg Res 2021; 16: 659 DOI: 10.1186/s13018-021-02775-x.
• 17 Bludau F, Winter L, Welzel G. et al. Long-term outcome after combined kyphoplasty and intraoperative radiotherapy (Kypho-IORT) for vertebral tumors. Radiat Oncol 2020; 15: 263 DOI: 10.1186/s13014-020-01715-z.
• 18 Prezzano KM, Prasad D, Hermann GM. et al. Radiofrequency Ablation and Radiation Therapy Improve Local Control in Spinal Metastases Compared to Radiofrequency Ablation Alone. Am J Hosp Palliat Care 2019; 36: 417-422 DOI: 10.1177/1049909118819460.
• 19 Husain ZA, Sahgal A, De Salles A. et al. Stereotactic body radiotherapy for de novo spinal metastases: systematic review. J Neurosurg Spine 2017; 27: 295-302 DOI: 10.3171/2017.1.SPINE16684.
• 20 Di Perna G, Cofano F, Mantovani C. et al. Separation surgery for metastatic epidural spinal cord compression: A qualitative review. J Bone Oncol 2020; 25: 100320 DOI: 10.1016/j.jbo.2020.100320.
• 21 Patchell RA, Tibbs PA, Regine WF. et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet 2005; 366: 643-648 DOI: 10.1016/S0140-6736(05)66954-1.
• 22 Laufer I, Iorgulescu JB, Chapman T. et al. Local disease control for spinal metastases following "separation surgery" and adjuvant hypofractionated or high-dose single-fraction stereotactic radiosurgery: outcome analysis in 186 patients. J Neurosurg Spine 2013; 18: 207-214 DOI: 10.3171/2012.11.SPINE12111.
• 23 Spratt DE, Beeler WH, de Moraes FY. et al. An integrated multidisciplinary algorithm for the management of spinal metastases: an International Spine Oncology Consortium report. Lancet Oncol 2017; 18: e720-e730 DOI: 10.1016/S1470-2045(17)30612-5.
• 24 Barzilai O, McLaughlin L, Amato MK. et al. Minimal Access Surgery for Spinal Metastases: Prospective Evaluation of a Treatment Algorithm Using Patient-Reported Outcomes. World Neurosurg 2018; 120: e889-e901 DOI: 10.1016/j.wneu.2018.08.182.
• 25 Hinojosa-Gonzalez DE, Roblesgil-Medrano A, Villarreal-Espinosa JB. et al. Minimally Invasive versus Open Surgery for Spinal Metastasis: A Systematic Review and Meta-Analysis. Asian Spine J 2022; 16: 583-597 DOI: 10.31616/asj.2020.0637.
• 26 Lu VM, Alvi MA, Goyal A. et al. The Potential of Minimally Invasive Surgery to Treat Metastatic Spinal Disease versus Open Surgery: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 112: e859-e868 DOI: 10.1016/j.wneu.2018.01.176.
• 27 Choi EH, Chan AY, Gong AD. et al. Comparison of Minimally Invasive Total versus Subtotal Resection of Spinal Tumors: A Systematic Review and Meta-Analysis. World Neurosurg 2021; 151: e343-e354 DOI: 10.1016/j.wneu.2021.04.045.
• 28 Barzilai O, Fisher CG, Bilsky MH. State of the Art Treatment of Spinal Metastatic Disease. Neurosurgery 2018; 82: 757-769 DOI: 10.1093/neuros/nyx567.
• 29 Osborn VW, Lee A, Yamada Y. Stereotactic Body Radiation Therapy for Spinal Malignancies. Technol Cancer Res Treat 2018; 17: 1533033818802304 DOI: 10.1177/1533033818802304.