手术治疗脊索瘤患者中放射治疗的作用：国家癌症数据库分析。
The Role of Radiotherapy for Chordoma Patients Managed With Surgery: Analysis of the National Cancer Database.
机构信息
Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC.
Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC.
出版信息
Spine (Phila Pa 1976). 2020 Jun 15;45(12):E742-E751. doi: 10.1097/BRS.0000000000003406.
STUDY DESIGN
Retrospective review.
OBJECTIVE
To determine if adjuvant radiation therapy (RT) improves overall survival (OS) following surgical resection of chordomas.
SUMMARY OF BACKGROUND DATA
The role of RT for the treatment of chordomas remains incompletely described. Previous studies have not found adjuvant RT to improve OS, but these studies did not group patients based on surgical margin status or radiation dose or modality. We used the National Cancer Database to investigate the role of RT in chordomas following surgical resection.
METHODS
Patients were stratified based on surgical margin status (positive vs. negative). Utilizing the Kaplan-Meier method, OS was compared between treatment modalities (surgical resection alone, therapeutic RT alone, and surgical resection plus therapeutic RT). OS was subsequently compared between patients treated with palliative dose (<40 Gy), low dose (40-65 Gy), and high dose (>65 Gy) RT. Similarly, OS was compared between advanced RT modalities including proton beam therapy (PBT) and intensity-modulated radiation therapy (IMRT), stereotactic radiosurgery (SRS), and external beam radiation therapy (EBRT). A multivariable model was used to determine adjusted variables predictive of mortality.
RESULTS
One thousand four hundred seventy eight chordoma patients were identified; skull base (n = 567), sacral (n = 551), and mobile spine (n = 360). Surgical resection and therapeutic adjuvant RT improved 5-year survival in patients with positive surgical margins (82% vs. 71%, P = 0.03). No clear survival benefit was observed with the addition of adjuvant RT in patients with negative surgical margins. High dose RT was associated with improved OS compared with palliative and low dose RT (P < 0.001). Advanced RT techniques and SRS were associated with improved OS compared with EBRT. In the multivariate analysis high dose advanced RT (>65 Gy) was superior to EBRT.
CONCLUSION
Patients with positive surgical margins benefit from adjuvant RT. Optimal OS is associated with adjuvant RT administered with advanced techniques and cumulative dose more than 65 Gy.
LEVEL OF EVIDENCE
研究设计
回顾性研究。
目的
确定手术切除脊索瘤后辅助放疗（RT）是否能提高总生存率（OS）。
背景资料概要
RT 治疗脊索瘤的作用仍不完全明确。先前的研究并未发现辅助 RT 能提高 OS，但这些研究没有根据手术切缘状态或放射剂量或方式对患者进行分组。我们利用国家癌症数据库研究了脊索瘤手术切除后 RT 的作用。
方法
根据手术切缘状态（阳性 vs. 阴性）对患者进行分层。利用 Kaplan-Meier 法比较治疗方式（单纯手术切除、单纯治疗性 RT 和手术切除加治疗性 RT）之间的 OS。随后比较接受姑息剂量（<40Gy）、低剂量（40-65Gy）和高剂量（>65Gy）RT 的患者的 OS。同样，比较质子束治疗（PBT）和强度调制放射治疗（IMRT）、立体定向放射外科（SRS）和外照射放射治疗（EBRT）等先进 RT 方式之间的 OS。使用多变量模型确定预测死亡率的调整变量。
结果
共确定了 1478 例脊索瘤患者；颅底（n=567）、骶骨（n=551）和移动脊柱（n=360）。手术切除和辅助治疗性 RT 改善了阳性手术切缘患者的 5 年生存率（82% vs. 71%，P=0.03）。在阴性手术切缘患者中，辅助 RT 似乎并未带来生存获益。与姑息性和低剂量 RT 相比，高剂量 RT 与 OS 改善相关（P<0.001）。与 EBRT 相比，先进 RT 技术和 SRS 与 OS 改善相关。在多变量分析中，高剂量先进 RT（>65Gy）优于 EBRT。
结论
阳性手术切缘的患者从辅助 RT 中获益。最佳 OS 与高级技术和累积剂量超过 65Gy 的辅助 RT 相关。
证据水平
4 级。
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