Li Yihao, Zheng Zezheng, He Qiuju
Department of Neurosurgery, Tongde Hospital of Zhejiang Province, Hangzhou, China.
Department of Neurosurgery, Yueqing People's Hospital, Yueqing, China.
World Neurosurg. 2025 Jan;193:1106-1116. doi: 10.1016/j.wneu.2024.10.092. Epub 2024 Nov 21.
The incidence rate of primary intramedullary spinal cord astrocytoma (IMSCA) is approximately 0.047 per 100,000 individuals per year, making it the second most common type of intramedullary spinal cord tumor. Due to its rarity, there is a scarcity of related research, and prognostic factors remain unclear. The aim of this study is to identify risk factors affecting the prognosis of patients with primary IMSCA. Based on these factors, we aim to develop and visualize a prognostic model for predicting the overall survival time of patients with this condition, thereby facilitating individualized predictions of overall survival time for patients with primary IMSCA.
This study selected patients diagnosed with primary IMSCA between 1975 and 2016 from the United States Surveillance, Epidemiology, and End Results database, incorporating a total of 582 eligible patients. We employed the Kaplan-Meier method for survival analysis of various factors to preliminary screen for potential prognostic influences. Univariate and multivariate Cox regression analyses were utilized to identify independent risk factors. A multivariate Cox regression model was constructed, and the model was visualized using a nomogram. Finally, various methods were applied to validate and evaluate the model.
Multivariate Cox analysis revealed that tumor grade, age, and surgical approach are independent prognostic factors for overall survival. A multivariate Cox regression model and a nomogram were developed based on these factors. The overall C-index of the model was 0.764, indicating good discriminative ability. Time-dependent receiver operating characteristic curve analysis showed the model had a good distinction with a 1-year survival rate area under the curve (AUC) of 0.801 (95% confidence interval [CI]: 0.763-0.839), a 3-year survival rate AUC of 0.842 (95% CI: 0.809-0.874), and a 10-year survival rate AUC of 0.855 (95% CI: 0.821-0.888). Calibration plots also demonstrated good model calibration. Decision curve analysis indicated that the nomogram had good clinical utility in predicting 1-year, 3-year, and 10-year overall survival. Internal validation based on enhanced bootstrap resampling showed good consistency between nomogram predictions and actual observations.
Lower World Health Organization's tumor grade, younger age groups, and undergoing gross total resection surgery are significant protective factors affecting the prognosis of patients with primary IMSCA. Among patients with Grade II astrocytoma, being female appears to be a protective factor, whereas being male seems to be a protective factor in Grade III astrocytoma. Radiation therapy and chemotherapy do not appear to improve long-term survival; specifically, radiation therapy may lead to worse outcomes for low-grade spinal cord astrocytomas. The study found no impact of tumor size, year of diagnosis, race, or marital status on prognosis. We have developed the first model and nomogram to predict the prognosis of patients with primary IMSCA, which demonstrates good predictive ability. The nomogram performed well in internal validation, offering a tool to help clinicians predict the overall survival time of patients with primary IMSCA on an individual basis.
原发性脊髓髓内星形细胞瘤（IMSCA）的发病率约为每年每10万人中有0.047例，是第二常见的脊髓髓内肿瘤类型。由于其罕见性，相关研究匮乏，预后因素仍不明确。本研究的目的是确定影响原发性IMSCA患者预后的危险因素。基于这些因素，我们旨在开发并可视化一个预测模型，以预测该疾病患者的总生存时间，从而便于对原发性IMSCA患者的总生存时间进行个体化预测。
本研究从美国监测、流行病学和最终结果数据库中选取了1975年至2016年间诊断为原发性IMSCA的患者，共纳入582例符合条件的患者。我们采用Kaplan-Meier方法对各种因素进行生存分析，以初步筛选潜在的预后影响因素。运用单因素和多因素Cox回归分析来确定独立危险因素。构建多因素Cox回归模型，并使用列线图对该模型进行可视化。最后，应用多种方法对模型进行验证和评估。
多因素Cox分析显示，肿瘤分级、年龄和手术方式是总生存的独立预后因素。基于这些因素建立了多因素Cox回归模型和列线图。该模型的总体C指数为0.764，表明具有良好的判别能力。时间依赖性受试者工作特征曲线分析显示，该模型具有良好的区分度，1年生存率曲线下面积（AUC）为0.801（95%置信区间[CI]：0.763 - 0.839），3年生存率AUC为0.842（95%CI：0.809 - 0.874），10年生存率AUC为0.855（95%CI：0.821 - 0.888）。校准图也显示模型校准良好。决策曲线分析表明，列线图在预测1年、3年和10年总生存方面具有良好的临床实用性。基于增强型自助重采样的内部验证显示，列线图预测与实际观察结果之间具有良好的一致性。
较低的世界卫生组织肿瘤分级、较年轻的年龄组以及接受全切除手术是影响原发性IMSCA患者预后的重要保护因素。在II级星形细胞瘤患者中，女性似乎是一个保护因素，而在III级星形细胞瘤中男性似乎是一个保护因素。放疗和化疗似乎并不能改善长期生存；具体而言，放疗可能会导致低级别脊髓星形细胞瘤的预后更差。研究发现肿瘤大小、诊断年份、种族或婚姻状况对预后没有影响。我们开发了首个预测原发性IMSCA患者预后的模型和列线图，其显示出良好的预测能力。列线图在内部验证中表现良好，为临床医生提供了一个有助于个体化预测原发性IMSCA患者总生存时间的工具。
