脊柱转移瘤的立体定向体部放疗：风险有哪些以及如何将其降至最低？
Stereotactic Body Radiotherapy for Spinal Metastases: What are the Risks and How Do We Minimize Them?
作者信息
Chang Joe H, Shin John H, Yamada Yoshiya J, Mesfin Addisu, Fehlings Michael G, Rhines Laurence D, Sahgal Arjun
机构信息
Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada.
Department of Neurosurgery, Massachusetts General Hospital, Harvard University, Boston, MA.
出版信息
Spine (Phila Pa 1976). 2016 Oct 15;41 Suppl 20(Suppl 20):S238-S245. doi: 10.1097/BRS.0000000000001823.
STUDY DESIGN
Systematic literature review.
OBJECTIVES
To summarize the risks of 3 key complications of stereotactic body radiotherapy (SBRT) for spinal metastases, that is, radiation myelopathy (RM), vertebral compression fracture (VCF), and epidural disease progression, and to discuss strategies for minimizing them.
SUMMARY OF BACKGROUND DATA
RM, VCF and epidural disease progression are now recognized as important risks following SBRT for spine metastases. It is unclear at this stage exactly how large these risks are and what strategies can be employed to minimize these risks.
METHODS
A systematic review of the literature using MEDLINE and a review of the bibliographies of reviewed articles on SBRT for spinal metastases were conducted.
RESULTS
The initial literature search revealed a total of 376 articles, of which 38 were pertinent to the study objectives. The risk of RM following SBRT was found to be dependent on the maximum dose to the spinal cord and estimated to be ≤5% if the recommended published thecal sac dose constraints are adhered to. The crude risk of VCF was 13.7% (range: 0.7%-40.5%), and, on average, 45% were surgically salvaged. It has been shown that the risk of VCF is dependent on several anatomic and tumor-related factors including the SBRT dose per fraction. The crude risk of local failure at 1 year was 21.4% (range: 12%-27%) of which 67% (range: 38%-96%) occurred within the epidural space. The grade of epidural disease has been shown to be associated with the risk of local failure.
CONCLUSION
The risk of RM after spinal SBRT is low in particular if recommended dose metrics are adhered to. There is a significant risk of both VCF and epidural disease progression after spinal SBRT. These risks can potentially be minimized by identifying the risk factors for these complications, and performing careful radiotherapy and surgical planning.
LEVEL OF EVIDENCE
研究设计
系统文献综述。
目的
总结立体定向体部放射治疗（SBRT）用于脊柱转移瘤的3种关键并发症的风险，即放射性脊髓病（RM）、椎体压缩骨折（VCF）和硬膜外疾病进展，并探讨将这些风险降至最低的策略。
背景数据总结
RM、VCF和硬膜外疾病进展目前被认为是SBRT治疗脊柱转移瘤后的重要风险。现阶段尚不清楚这些风险究竟有多大，以及可采用何种策略将这些风险降至最低。
方法
使用MEDLINE对文献进行系统综述，并查阅关于SBRT治疗脊柱转移瘤的综述文章的参考文献。
结果
初步文献检索共发现376篇文章，其中38篇与研究目的相关。发现SBRT后发生RM的风险取决于脊髓的最大剂量，如果遵循推荐的已发表的硬膜囊剂量限制，则估计风险≤5%。VCF的粗略风险为13.7%（范围：0.7%-40.5%），平均有45%通过手术挽救。已表明VCF的风险取决于几个解剖学和肿瘤相关因素，包括每分次SBRT剂量。1年时局部失败的粗略风险为21.4%（范围：12%-27%），其中67%（范围：38%-96%）发生在硬膜外间隙。已表明硬膜外疾病的分级与局部失败的风险相关。
结论
脊柱SBRT后发生RM的风险较低，特别是如果遵循推荐的剂量指标。脊柱SBRT后VCF和硬膜外疾病进展均存在显著风险。通过识别这些并发症的风险因素，并进行仔细的放射治疗和手术规划，这些风险有可能降至最低。
证据级别
2级。
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