中-低恶性程度的孤立性颈胸段脊柱转移瘤的手术疗效及生存分析

背景　颈胸段脊柱（CTJS）转移瘤多伴发严重疼痛及神经症状,对患者的生存时间影响亦较大。当转移瘤生物学行为是中-低恶性程度,并且孤立存在时,其手术效果以及生存时间如何,目前国内外报道均较少。　目的　探讨孤立性、原发肿瘤中-低恶性程度CTJS转移瘤的手术疗效及生存情况。方法　选择北京大学第三医院2011年1月-2015年5月收治的10例CTJS转移瘤患者为研究对象,均为孤立性、原发肿瘤中-低恶性程度且原发灶控制良好。采用整块切除或分块切除的手术方法予以广泛或边缘的转移瘤完全切除。采用视觉模拟评分法（VAS）评分、神经功能评估按脊髓损伤功能评定（Frankel分级）、美国东部肿瘤协作组（ECOG）评分对疼痛、功能状况和脊髓功能进行评价,采用Kaplan-Meier法评估生存时间。结果　手术时间为160~410 min,平均（262.2±85.7）min;术中出血量为800~3 200 ml,平均（1 770.0±766.0）ml。1例患者术中胸膜破裂,1例患者术后脑脊液瘘,1例患者术后出现双下肢肌力下降。VAS评分〔（2.10±0.99）分〕低于术前〔（6.20±1.48）分〕（t配对=22.841,P<0.001）。10例患者中9例伴有不全截瘫或截瘫,术后7例神经功能Frankel分级至少改善一个等级,评分由术前（3.30±1.16）分提高到术后（4.20±0.63）分（t配对=3.857,P=0.004）。患者术后功能状态均较术前好转,ECOG评分由术前（2.60±0.97）分下降到术后（1.80±0.63）分（t配对=4.000,P=0.003）。除1例死于心脏疾病外,其余患者中位生存时间为54个月,两种手术方式的术后生存时间比较,差异无统计学意义（χ2=0.471,P=0.493）。结论　对孤立性、原发肿瘤中-低恶性程度、原发灶控制良好的CTJS转移瘤患者的手术治疗可以缓解其疼痛,改善其神经功能和提高其生活质量。无论是转移瘤整块还是分块切除,当切除范围达到广泛或边缘时,术后生存时间均令人满意。

Surgical Efficacy and Survival Analysis of Low-to-medium Grade Solitary Malignant Tumor Metastatic to the Cervicothoracic Junction

Background　Most tumors metastatic to the cervicothoracic junction spine（CTJS） are accompanied with severe pain and neurological symptoms,greatly impairing the survival time of patients.There are few reports on the surgical efficacy and survival time of patients with a solitary tumor of low-to-medium grade malignancy metastatic to the CTJS.Objective　To investigate the surgical efficacy and survival time in patients with a low-to-medium grade solitary malignant tumor metastatic to the CTJS.Methods　Ten participants with a low-to-medium grade solitary malignant tumor metastatic to the CTJS and good local tumor control in the primary site were recruited from Peking University Third Hospital from January 2011 to May 2015.The metastatic tumor in them was completely removed by en-bloc spondylectomy or block vertebral resection,with an extensive or marginal resection range.Pain,functional outcome,neurological deficit and survival status were measured with visual analogue scale（VAS）,Frankel Scale,Eastern Cooperative Oncology Group（ECOG） Scale,and the Kaplan-Meier curve,respectively.Results　The mean operative time was（262.2±85.7） min（range,160-410 min）.And the mean intraoperative blood loss was（1 770.0±766.0）ml（range,800-3 200 ml）.Complications included intraoperative pleural rupture（n=1）,postoperative cerebrospinal fluid fistula（n=1）,and reduced postoperative lower extremity muscle strength（n=1）.VAS score decreased from（6.20±1.47） points before surgery to（2.10±0.99） points after surgery（tpair=22.841,P<0.001）.Before operation,9 out of 10 cases were accompanied with incomplete paraplegia or paraplegia.After surgery,7 cases improved at least one grade of Frankel score.And the score increased from preoperative（3.30±1.16） points to postoperative（4.20±0.63） points（tpair=3.857,P=0.004）.The functional outcome of patients got better after surgery.ECOG score decreased from（2.60±0.97） points before surgery to（1.80±0.63） points after surgery（tpair=4.000,P=0.003）.Except for 1 case who died of heart disease,the median survival time of others was 54 months.There was no significant difference in post-operative survival between the two surgical methods（χ2=0.471,P=0.493）.Conclusion　For patients with a solitary tumor of low-to-medium grade malignancy metastatic to the CTJS and a well-controlled primary lesion,surgical treatment may improve the neurological status and enhance the quality of life.Moreover,either en-bloc spondylectomy or block vertebral resection may achieve satisfactory postoperative survival time if the resection range is extensive or marginal.