今日の臨床サポート

腫瘍による脊髄圧迫

著者: 土井美帆子 県立広島病院 臨床腫瘍科

監修: 金子周一 金沢大学大学院

著者校正/監修レビュー済:2020/11/06
参考ガイドライン:
  1. 日本臨床腫瘍学会:骨転移診療ガイドライン 2015年版
  1. 英国国立医療技術評価機構(NICE)ガイドライン:成人の転移性脊髄圧迫 2019年版
  1. 日本緩和医療学会:がん疼痛の薬物療法に関するガイドライン 2020年版
患者向け説明資料

概要・推奨   

  1. 病歴やCT検査で、悪性腫瘍に伴う脊髄圧迫が疑われる患者には、緊急MRI検査を考慮する。原発腫瘍の診断が未確定であっても、脊髄圧迫に対する治療を開始することが勧められる(推奨度1)
  1. 悪性腫瘍に伴う脊髄機能障害、神経根障害は、脊髄圧迫のほか、癌性髄膜炎、髄内転移、硬膜外膿瘍などがみられ、診断にはMRI検査が有用である。
  1. 脊髄圧迫を伴う患者のほとんどに背部痛を認め、しばしば運動機能低下や知覚変化、膀胱機能低下を認める。多発骨転移や骨転移診断後の経過が長い症例では、本病態の出現の可能性を念頭に置く必要がある(推奨度1)
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧に
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要とな
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要とな
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要とな
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
土井美帆子 : 特に申告事項無し[2021年]
監修:金子周一 : 研究費・助成金など(バイエル薬品株式会社,株式会社キュービクス,アボットジャパン合同会社,日東電工株式会社,株式会社スギ薬局,株式会社サイトパスファインダー),奨学(奨励)寄付など(小野薬品工業株式会社,エーザイ株式会社,株式会社ツムラ,アッヴィ合同会社,大日本住友製薬株式会社,ゼリア新薬工業株式会社,塩野義製薬株式会社,大塚製薬株式会社,アステラス製薬株式会社,田辺三菱製薬株式会社,マイランEPD合同会社,EAファーマ株式会社,大鵬薬品工業株式会社,中外製薬株式会社,協和キリン株式会社,持田製薬株式会社,日本ケミファ株式会社,LifeScan Japan株式会社)[2021年]

改訂のポイント:
  1. 定期レビューを行い、全体を通して確認と改訂を行った。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 脊髄圧迫症候群は、非可逆的な対麻痺を来しうるオンコロジーエマージェンシーの病態である。
  1. 腫瘍による脊髄圧迫の初発症状は背部痛が多く、進行すると非可逆的な神経麻痺を生じうる。
  1. 癌患者の約5%に認められ、その原因の約85~90%は椎骨転移によるものである。
  1. 脊柱に転移するあらゆる腫瘍により脊髄圧迫が生じうるが、肺癌、乳癌、多発性骨髄腫、ホジキン・非ホジキンリンパ腫、前立腺癌に多くみられる。
  1. 胸椎に60%、腰椎に30%、頚椎に10%の割合で生じる。肺癌では胸椎、腎癌、前立腺癌、消化器癌では下位胸椎や腰椎に多くみられる。
  1. 脊髄圧迫の治療は、治療前の神経症状、全身状態や予後などを総合して、放射線療法、手術療法、緩和治療を組み合わせて行う。
  1. 症状出現から治療開始までの期間、治療開始時の神経症状が、神経学的予後、全体の予後を左右するため、速やかな診断と治療開始が重要となる。
問診・診察のポイント  
  1. 背部痛が初発症状として多くみられ、診断時に83~95%の患者にみられる。その他の神経症状に先行し平均的には7週前から認められる。進行するにつれ、痛みは根性となる。胸部の根性痛は、通常両側性で帯状に前方へ分布する。脊椎の動きやバルサルバ手技により、四肢に痛みが放散する。突然の痛みは病的骨折を示唆する。

今なら12か月分の料金で14ヶ月利用できます(個人契約、期間限定キャンペーン)

11月30日(火)までにお申込みいただくと、
通常12ヵ月の使用期間が2ヶ月延長となり、14ヵ月ご利用いただけるようになります。

詳しくはクリック
本サイトの知的財産権は全てエルゼビアまたはコンテンツのライセンサーに帰属します。私的利用及び別途規定されている場合を除き、本サイトの利用はいかなる許諾を与えるものでもありません。 本サイト、そのコンテンツ、製品およびサービスのご利用は、お客様ご自身の責任において行ってください。本サイトの利用に基づくいかなる損害についても、エルゼビアは一切の責任及び賠償義務を負いません。 また、本サイトの利用を以て、本サイト利用者は、本サイトの利用に基づき第三者に生じるいかなる損害についても、エルゼビアを免責することに合意したことになります。  本サイトを利用される医学・医療提供者は、独自の臨床的判断を行使するべきです。本サイト利用者の判断においてリスクを正当なものとして受け入れる用意がない限り、コンテンツにおいて提案されている検査または処置がなされるべきではありません。 医学の急速な進歩に鑑み、エルゼビアは、本サイト利用者が診断方法および投与量について、独自に検証を行うことを推奨いたします。

文献 

著者: J A Talcott, P C Stomper, F W Drislane, P Y Wen, C C Block, C C Humphrey, C Lu, F Jolesz
雑誌名: Support Care Cancer. 1999 Jan;7(1):31-8.
Abstract/Text The object of this work was to evaluate the assessment and document the outcomes of cancer patients with suspected spinal cord compression (SCC). In a retrospective cohort study of 342 episodes of suspected SCC in cancer patients evaluated by computed tomography (CT) of the spine, a multidisciplinary team of neurologists, radiologists, and oncologists assessed the impact of varying the anatomical criterion for SCC and including new SCC diagnosed shortly after definitive radiographical imaging. We developed a logistic regression model to identify independent clinical predictors of SCC, including the natural history of the underlying cancer as well as neurological and radiological risk factors. Management of suspected SCC infrequently involved neurology consultation (21% of episodes). The frequency of SCC increased more than four-fold when the definition was expanded to include epidural cancer rather than spinal cord displacement only (36% vs. 8%), and 90-day clinical follow-up identified few new lesions not evident on definitive imaging studies. Clinical information about the course of cancer (documentation and duration of metastatic cancer) added independent predictive information to that yielded by neurological assessment and prior imaging studies in a multiple regression model. The a priori predicted risk of SCC, which ranged from 4% to 87% in this study, may vary enough to affect treatment strategies, although our population may have excluded very-low-risk patients. Consistent anatomical definitions of SCC, clinical follow-up of definitive imaging studies and the addition of information on the natural history of cancer to traditional neurological and radiographical evaluation may all improve clinical assessment of suspected SCC in cancer patients.

PMID 9926972  Support Care Cancer. 1999 Jan;7(1):31-8.
著者: A Bayley, M Milosevic, R Blend, J Logue, M Gospodarowicz, I Boxen, P Warde, M McLean, C Catton, P Catton
雑誌名: Cancer. 2001 Jul 15;92(2):303-10.
Abstract/Text BACKGROUND: The objective of this study was to identify clinical parameters that predict occult subarachnoid space or spinal cord (SAS/SC) compression, as determined by magnetic resonance imaging (MRI), in patients with metastatic prostate carcinoma.
METHODS: A prospective study was performed in which 68 patients with bone metastases from prostate carcinoma and a normal neurologic examination underwent MRI of the entire spine after documentation of clinical, X-ray, and bone scan parameters potentially predictive of occult SAS/SC compression.
RESULTS: Occult SAS/SC compression was diagnosed in 22 patients (32%) using MRI. Nine patients (13%) had compressions at two discontinuous spinal levels. Extensive disease on bone scan, the duration of continuous hormonal therapy prior to study entry, and hemoglobin concentration were found to predict SAS/SC compression by univariate analysis. The extent of disease on bone scan and the duration of continuous hormonal therapy were independent predictors of SAS/SC compression by multivariate analysis (P = 0.02 and P = 0.04, respectively). The risk of occult SAS/SC compression increased from 32% to 44% in patients with a bone scan that showed > 20 metastases as the duration on hormones increased from 0 to 24 months. The risk in patients with fewer metastases increased from 11% to 17% over the same interval. The presence or absence of back pain was not predictive of SAS/SC compression.
CONCLUSIONS: Patients who are at high risk for occult SAS/SC compression can be identified using clinical parameters and readily available diagnostic tests. These high-risk patients should undergo MRI screening with the aim of diagnosing and treating spinal cord compression before the development of neurologic deficits that may be irreversible.

Copyright 2001 American Cancer Society.
PMID 11466683  Cancer. 2001 Jul 15;92(2):303-10.
著者: K C Li, P Y Poon
雑誌名: Magn Reson Imaging. 1988 Sep-Oct;6(5):547-56.
Abstract/Text The accuracy of magnetic resonance (MR) imaging in the detection of metastatic compression of the spinal cord and the cauda equina (MCCE) in 75 patients with known primary malignancy outside the central nervous system is determined retrospectively by comparing the MR results with findings of myelography, surgery, clinical follow-up and autopsy. The sensitivity is 93%, the specificity 97% and the overall accuracy 95%. The signal intensity measured in the sagittal MR images of a collapsed vertebral body is divided by that of an average of three adjacent normal vertebrae to form a signal intensity ratio (SIR). The SIRs of 41 metastatic and 15 post-traumatic collapsed vertebrae are calculated. A ratio of 0.8 has the most differentiating power. All benign and one malignant compressed vertebrae have SIRs greater than 0.8.

PMID 3067022  Magn Reson Imaging. 1988 Sep-Oct;6(5):547-56.
著者: D J Husband, K A Grant, C S Romaniuk
雑誌名: Br J Radiol. 2001 Jan;74(877):15-23.
Abstract/Text It remains unclear whether MRI is essential in all patients with suspected malignant spinal cord compression (MSCC), or whether some patients can be treated on the basis of plain radiographic findings and neurological examination. A prospective study was carried out of 280 consecutive patients with suspected MSCC, and the results of neurological examination plus plain radiographs were compared with MRI. 201 patients had MSCC (186 extradural, 5 intradural extramedullary and 10 intramedullary) and 11 patients had thecal sac compression without evidence of spinal cord compression. 25% of patients with MSCC had two or more levels of compression, 69% of these involving more than one region of the spine. A paraspinal mass was noted at the site of extradural spinal cord compression in 28%, and only one-third of these were detected on plain radiography. Focal radiographic changes and consistent neurology were present in 91 (33%) patients who had not had previous radiotherapy. MRI confirmed the presence of MSCC in 89/91 patients (specificity and positive predictive value of radiographic/clinical findings 98%) and the level of disease in all. MRI led to a change in the radiotherapy plan in 53% of patients (21% major change). The sensory level when present was four or more segments below the MRI level in 25/121 (21%) patients, and two or more levels above in 8/121 (7%) patients. Although focal radiographic abnormalities with consistent neurological findings, when present, accurately predicted the presence and level of MSCC, whole spine MRI is indicated in most patients with suspected MSCC because the additional information may alter the management plan. Treatment may be appropriately initiated on the basis of focal radiographic changes and consistent neurology if MRI is contraindicated or delayed, and in patients with a poor prognosis. In patients in whom there are no focal radiographic abnormalities and consistent neurological findings, urgent MRI is mandatory before radiotherapy is commenced.

PMID 11227772  Br J Radiol. 2001 Jan;74(877):15-23.
著者: R F Carmody, P J Yang, G W Seeley, J F Seeger, E C Unger, J E Johnson
雑誌名: Radiology. 1989 Oct;173(1):225-9. doi: 10.1148/radiology.173.1.2675185.
Abstract/Text To determine the efficacy of magnetic resonance (MR) imaging and myelography for the diagnosis of spinal cord compression due to metastatic disease, the authors prospectively examined 70 patients who had known or suspected spinal involvement by malignancy. Most MR examinations consisted of T1-weighted sagittal imaging of the entire spine, with additional sequences as needed for clarification. Extradural masses were found in 46 patients, 25 of whom had cord compression. For extradural masses causing cord compression, the sensitivity and specificity of MR imaging was .92 and .90, respectively, compared with .95 and .88 for myelography. For extradural masses without cord compression the sensitivity and specificity of MR imaging was .73 and .90, versus .49 and .88 for myelography. MR imaging was much more sensitive for metastases to bone (.90 vs .49), as expected. MR imaging is an acceptable alternative to myelography for diagnosing spinal cord compression and is preferable as a first study because it is noninvasive and better tolerated.

PMID 2675185  Radiology. 1989 Oct;173(1):225-9. doi: 10.1148/radiolog・・・
著者: C Hagenau, W Grosh, M Currie, R G Wiley
雑誌名: J Clin Oncol. 1987 Oct;5(10):1663-9.
Abstract/Text Spinal involvement by systemic malignancy is common, and often leads to extradural compression of the spinal cord and/or nerve roots by metastases. Rapid, anatomically accurate diagnosis is essential to the successful management of these patients. We compared spinal magnetic resonance imaging (MRI) with conventional myelography in a series of 31 cancer patients being evaluated for myelopathy (N = 10), or back/radicular pain (N = 21). All patients were evaluated between April 1985 and July 1986, and underwent both studies within ten days of each other (median, two days). MRI was performed on a 0.5 Tesla Technicare unit with a body surface coil, and results compared with standard contrast myelography. All studies were reviewed separately and in a "blinded" fashion. MRI and myelography were comparable in detecting large lesions that produced complete subarachnoid block (five of ten patients with myelopathy, three of twenty-one patients with back/radicular pain). In 19 of 31 patients, smaller but clinically significant extradural lesions were found. In nine of 19 cases, these lesions were demonstrated equally well by both modalities; in nine of 19 cases, these lesions were demonstrated by myelography alone; in one of 19, a lesion was demonstrated by MRI alone. Given our current technology, myelography appeared superior to MRI as a single imaging modality. However, MRI may be an alternative in patients where total myelography is technically impossible or unusually hazardous.

PMID 3655863  J Clin Oncol. 1987 Oct;5(10):1663-9.
著者: S Helweg-Larsen, P S Sørensen, S Kreiner
雑誌名: Int J Radiat Oncol Biol Phys. 2000 Mar 15;46(5):1163-9. doi: 10.1016/s0360-3016(99)00333-8.
Abstract/Text PURPOSE: Based on a very large patient cohort followed prospectively for at least a year or until death, we analyzed the prognostic significance of various clinical and radiological variables on posttreatment ambulatory function and survival.
METHODS AND MATERIALS: During a 312-year period we prospectively included 153 consecutive patients with a diagnosis of spinal cord compression due to metastatic disease. The patients were followed with regular neurological examinations by the same neurologist for a minimum period of 11 months or until death. The prognostic significance of five variables on gait function and survival time after treatment was analyzed.
RESULTS: The type of the primary tumor had a direct influence on the interval between the diagnosis of the primary malignancy and the occurrence of spinal cord compression (p < 0. 0005), and on the ambulatory function at time of diagnosis (p = 0. 016). There was a clear correlation between the degree of myelographic blockage and gait function (p = 0.000) and between gait function and sensory disturbances (p = 0.000). The final gait was dependent on the gait function at time of diagnosis (p < 0.0005). Survival time after diagnosis depended directly on the time from primary tumor diagnosis until spinal cord compression (p = 0.002), on the ambulatory function at the time of diagnosis (p = 0.018), and on the ambulatory function after treatment.
CONCLUSIONS: The pretreatment ambulatory function is the main determinant for posttreatment gait function. Survival time is rather short, especially in nonambulatory patients, and can only be improved by restoration of gait function in nonambulatory patients by immediate treatment.

PMID 10725627  Int J Radiat Oncol Biol Phys. 2000 Mar 15;46(5):1163-9.・・・
著者: Sten Myrehaug, Arjun Sahgal, Motohiro Hayashi, Marc Levivier, Lijun Ma, Roberto Martinez, Ian Paddick, Jean Régis, Samuel Ryu, Ben Slotman, Antonio De Salles
雑誌名: J Neurosurg Spine. 2017 Oct;27(4):428-435. doi: 10.3171/2017.2.SPINE16976. Epub 2017 Jul 14.
Abstract/Text OBJECTIVE Spinal metastases that recur after conventional palliative radiotherapy have historically been difficult to manage due to concerns of spinal cord toxicity in the retreatment setting. Spine stereotactic body radiation therapy (SBRT), also known as stereotactic radiosurgery, is emerging as an effective and safe means of delivering ablative doses to these recurrent tumors. The authors performed a systematic review of the literature to determine the clinical efficacy and safety of spine SBRT specific to previously irradiated spinal metastases. METHODS A systematic literature review was conducted, which was specific to SBRT to the spine, using MEDLINE, Embase, Cochrane Evidence-Based Medicine Database, National Guideline Clearinghouse, and CMA Infobase, with further bibliographic review of appropriate articles. Research questions included: 1) Is retreatment spine SBRT efficacious with respect to local control and symptom control? 2) Is retreatment spine SBRT safe? RESULTS The initial literature search retrieved 2263 articles. Of these articles, 160 were potentially relevant, 105 were selected for in-depth review, and 9 studies met all inclusion criteria for analysis. All studies were single-institution series, including 4 retrospective, 3 retrospective series of prospective databases, 1 prospective, and 1 Phase I/II prospective study (low- or very low-quality data). The results indicated that spine SBRT is effective, with a median 1-year local control rate of 76% (range 66%-90%). Improvement in patients' pain scores post-SBRT ranged from 65% to 81%. Treatment delivery was safe, with crude rates of vertebral body fracture of 12% (range 0%-22%) and radiation-induced myelopathy of 1.2%. CONCLUSIONS This systematic literature review suggests that SBRT to previously irradiated spinal metastases is safe and effective with respect to both local control and pain relief. Although the evidence is limited to low-quality data, SBRT can be a recommended treatment option for reirradiation.

PMID 28708043  J Neurosurg Spine. 2017 Oct;27(4):428-435. doi: 10.3171・・・
著者: Ilya Laufer, Andrew Hanover, Eric Lis, Yoshiya Yamada, Mark Bilsky
雑誌名: J Neurosurg Spine. 2010 Jul;13(1):109-15. doi: 10.3171/2010.3.SPINE08670.
Abstract/Text OBJECT In this paper, the authors' goal was to determine the outcome of reoperation for recurrent epidural spinal cord compression in patients with metastatic spine disease. METHODS A retrospective chart review was conducted of all patients who underwent spine surgery at the Memorial Sloan-Kettering Cancer Center between 1996 and 2007. Thirty-nine patients who underwent reoperation of the spine at the level previously treated with surgery were identified. Only patients whose reoperation was performed because of tumor recurrence leading to high-grade epidural spinal cord compression or recurrence with no further radiation options were included in the study. Patients who underwent reoperations exclusively for instrumentation failure were excluded. All patients underwent additional decompression via a posterolateral approach without removal of the spinal instrumentation. RESULTS Patients underwent 1-4 reoperations at the same level. A median survival time of 12.4 months was noted after the first reoperation, and a median survival time of 9.1 months was noted after the last reoperation. At last follow-up 22 (65%) of 34 patients were ambulatory at the time of last follow-up or death, and the median time between loss-of-ambulation and death was 1 month. Functional status was maintained or improved by one Eastern Cooperative Oncology Group grade in 97% of patients. A major surgical complication rate of 5% was noted. CONCLUSIONS Reoperation represents a viable option in patients with high-grade epidural spinal cord compression who have recurrent metastatic tumors at previously operated spinal levels. In carefully selected patients, reoperation can prolong ambulation and result in good functional and neurological outcomes.

PMID 20594025  J Neurosurg Spine. 2010 Jul;13(1):109-15. doi: 10.3171/・・・
著者: Janet L Abrahm, Michael B Banffy, Mitchel B Harris
雑誌名: JAMA. 2008 Feb 27;299(8):937-46. doi: 10.1001/jama.299.8.937.
Abstract/Text As 1 of the 12,700 US cancer patients who, each year, develops metastatic spinal cord compression, Ms H wishes to walk and live her life. Sadly, this wish may be difficult to fulfill. Before diagnosis, 83% to 95% of patients experience back pain, which often is referred, obscuring the site(s) of the compression(s). Prediction of ambulation depends on a patient's ambulatory status before therapy and time between developing motor defects and starting therapy. Ambulatory patients with no visceral metastases and more than 15 days between developing motor symptoms and receiving therapy have the best rate of survival. To preserve ambulation and optimize survival, magnetic resonance imaging should be performed for cancer patients with new back pain despite normal neurological findings. At diagnosis, counseling, pain management, and corticosteroids are begun. Most patients are offered radiation therapy. Surgery followed by radiation is considered for selected patients with a single high-grade epidural lesion caused by a radioresistant tumor who also have an estimated survival of more than 3 months. Team discussions with the patient and support network help determine therapy options and include patient goals; assessment of risks, benefits, and burdens of each treatment; and discussion of the odds of preserving prognosis of ambulation and of the effect of therapy on the patient's overall prognosis. Rehabilitation improves impaired function and its associated depression. Clinicians can help patients cope with transitions in self-image, independence, family and community roles, and living arrangements and can help patients with limited prognoses identify their end-of-life goals and preferences about resuscitation and entering hospice.

PMID 18314436  JAMA. 2008 Feb 27;299(8):937-46. doi: 10.1001/jama.299.・・・
著者: E Maranzano, P Latini, S Beneventi, E Perruci, B M Panizza, C Aristei, M Lupattelli, M Tonato
雑誌名: Am J Clin Oncol. 1996 Apr;19(2):179-83.
Abstract/Text A phase II trial was planned to investigate the feasibility of radiotherapy (RT) without steroids in 20 consecutive patients with metastatic spinal cord compression (MSCC), no neurologic deficits, or only radiculopathy, and no massive invasion of the spine at magnetic resonance imaging (MRI) or computed tomography (CT). Aiming at an early diagnosis, MRI or CT was prescribed for all cancer patients with back pain and osteolysis, even when there were no signs of neurologic spinal compression. All patients were given 30 Gy in 10 fractions over 2 weeks with no steroids. Back pain and motor capacity were the parameters adopted to verify response to RT. Sixteen of 20 patients (80%) were able to walk without support, and 14 (70%) had no radiculopathy. Seventeen of 20 cases (85%) achieved relief from back pain. Regarding motor function, all patients (100%) responded to RT because the 16 patients able to walk without support at diagnosis did not deteriorate and the other 4, who needed support, became ambulatory without motor impairment. Median survival time was 14 months. Eight of 20 (40%) treated patients are still alive (14 to 36 months after end of RT), fully ambulatory, and free from relapse in the treated spine. Acute side effects were documented in only 2 patients (10%) and were managed without steroids. The results of this study suggest that RT without steroids is a feasible regimen for MSCC patients with good motor function. Elimination of steroids from the standard treatment for MSCC avoids cortisone side effects above all in those patients with diabetes, hypertension, peptic ulcer, and other steroid-sensitive medical problems.

PMID 8610645  Am J Clin Oncol. 1996 Apr;19(2):179-83.
著者: Reena George, Jenifer Jeba, Govindraj Ramkumar, Ari G Chacko, Mhoira Leng, Prathap Tharyan
雑誌名: Cochrane Database Syst Rev. 2008 Oct 8;(4):CD006716. doi: 10.1002/14651858.CD006716.pub2. Epub 2008 Oct 8.
Abstract/Text BACKGROUND: Metastatic epidural spinal cord compression (MESCC) is often treated with radiotherapy and corticosteroids. Recent reports suggest benefit from decompressive surgery.
OBJECTIVES: To determine effectiveness and adverse effects of radiotherapy, surgery and corticosteroids in MESCC.
SEARCH STRATEGY: CENTRAL, MEDLINE, EMBASE, CINAHL, LILACS and CANCERLIT were searched; last search ran July 2008
SELECTION CRITERIA: We selected randomized controlled trials (RCTs) of radiotherapy, surgery and corticosteroids in adults with MESCC.
DATA COLLECTION AND ANALYSIS: Three review authors independently assessed quality of included studies and extracted data. We calculated risk ratios (RR) and numbers needed to treat to benefit (NNT) with 95% confidence intervals (CI) and assessed heterogeneity.
MAIN RESULTS: We identified six trials (n = 544). One trial (n = 276) compared radiotherapy 30 Gray in eight fractions with 16 Gray in two fractions and showed no difference. Overall ambulatory rates were 71% versus 68%, (RR 1.02, CI 0.90 to 1.15); 91% versus 89% of ambulant patients maintained ambulation (RR 1.02, CI 0.93 to 1.12); 28% versus 29% of non-ambulant patients regained ambulation (RR 0.98, CI 0.51 to 1.88). In one trial (n = 101) decompressive surgery had significantly better outcomes than radiotherapy in selected patients. Overall ambulatory rates were 84% versus 57% (RR 0.67, CI 0.53 to 0.86, NNT 3.70 CI 2.38 to 7.69); 94% versus 74% maintained ambulation (RR 0.79, CI 0.64 to 0.98, NNT 5.00 CI 2.78 to 33.33); 63% versus 19% regained ambulation (RR 0.30, CI 0.10 to 0.89; NNT 2.27 CI 1.35 to 7.69). Median survival was 126 days versus 100 days. Laminectomy offered no advantage (n = 29, 1 trial). Three trials provided insufficient evidence about the role of corticosteroids (n = 105, Overall ambulation RR 0.91, CI 0.68 to 1.23). Serious adverse effects were significantly higher in high dose corticosteroid arms (n = 77, two RCTs, RR 0.12, CI 0.02 to 0.97).
AUTHORS' CONCLUSIONS: Patients with stable spines retaining the ability to walk may be treated with radiotherapy. One trial indicates that short course radiotherapy suffices in patients with unfavourable histologies or predicted survival of less than six months. There is some evidence of benefit from decompressive surgery in ambulant patients with poor prognostic factors for radiotherapy; and in non-ambulant patients with a single area of compression, paraplegia < 48 hours, non-radiosensitive tumours and a predicted survival of more than three months. High dose corticosteroids carry a significant risk of serious adverse effects.

PMID 18843728  Cochrane Database Syst Rev. 2008 Oct 8;(4):CD006716. do・・・
著者: S Sørensen, S Helweg-Larsen, H Mouridsen, H H Hansen
雑誌名: Eur J Cancer. 1994;30A(1):22-7.
Abstract/Text We performed a randomised single blind trial of high-dose dexamethasone as an adjunct to radiotherapy in patients with metastatic spinal cord compression from solid tumours. After stratification for primary tumour and gait function, 57 patients were allocated randomly to treatment with either high-dose dexamethasone or no steroidal treatment. Dexamethasone was administered as a bolus of 96 mg intravenously, followed by 96 mg orally for 3 days and then tapered in 10 days. A successful treatment result defined as gait function after treatment was obtained in 81% of the patients treated with dexamethasone compared to 63% of the patients receiving no dexamethasone therapy. Six months after treatment, 59% of the patients in the dexamethasone group were still ambulatory compared to 33% in the no dexamethasone group. Life table analysis of patients surviving with gait function showed a significantly better course in patients treated with dexamethasone (P < 0.05). Median survival was identical in the two treatment groups. Similar results were found in subgroup analysis of 34 patients with breast cancer as the primary malignancy. Significant side-effects were reported in 3 (11%) of the patients receiving glucocorticoids, 2 of whom discontinued the treatment. We conclude that high-dose glucocorticoid therapy should be given as adjunct treatment in patients with metastatic epidural spinal cord compression.

PMID 8142159  Eur J Cancer. 1994;30A(1):22-7.
著者: C J Vecht, H Haaxma-Reiche, W L van Putten, M de Visser, E P Vries, A Twijnstra
雑誌名: Neurology. 1989 Sep;39(9):1255-7.
Abstract/Text We randomly assigned dexamethasone in an initial bolus of 10 mg IV or 100 mg IV followed by 16 mg daily orally to 37 patients with metastatic spinal cord compression. The average pain score before the start of treatment was 5.2 (SD = 2.8) and decreased significantly (p less than 0.001) to 3.8 at 3 hrs, 2.8 at 24 hrs, and 1.4 after 1 week. There were no differences between the conventional and high-dose group on pain, ambulation, or bladder function.

PMID 2771077  Neurology. 1989 Sep;39(9):1255-7.
著者: D Andrew Loblaw, James Perry, Alexandra Chambers, Normand J Laperriere
雑誌名: J Clin Oncol. 2005 Mar 20;23(9):2028-37. doi: 10.1200/JCO.2005.00.067.
Abstract/Text PURPOSE: This systematic review describes the diagnosis and management of adult patients with a suspected or confirmed diagnosis of extradural malignant spinal cord compression (MSCC).
METHODS: MEDLINE, CANCERLIT, and the Cochrane Library databases were searched to January 2004 using the following terms: spinal cord compression, nerve compression syndromes, spinal cord neoplasms, clinical trial, meta-analysis, and systematic review.
RESULTS: Symptoms for MSCC include sensory changes, autonomic dysfunction, and back pain; however, back pain was not predictive of MSCC. The sensitivity and specificity for magnetic resonance imaging (MRI) range from 0.44 to 0.93 and 0.90 to 0.98, respectively, in the diagnosis of MSCC. The sensitivity and specificity for myelography range from 0.71 to 0.97 and 0.88 to 1.00, respectively. A randomized study detected higher ambulation rates in patients with MSCC who received high-dose dexamethasone before radiotherapy (RT) compared with patients who did not receive corticosteroids before RT (81% v 63% at 3 months, respectively; P = .046). There is no direct evidence that supports or refutes the type of surgery patients should have for the treatment of MSCC, whether surgical salvage should be attempted if patient is progressing on or shortly after RT, and whether patients with spinal instability should be treated with surgery.
CONCLUSION: Patients with symptoms of MSCC should be managed to minimize treatment delay. MRI is the preferred imaging technique. Treatment for patients with MSCC should consider pretreatment ambulatory status, comorbidities, technical surgical factors, the presence of bony compression and spinal instability, potential surgical complications, potential RT reactions, and patient preferences.

PMID 15774794  J Clin Oncol. 2005 Mar 20;23(9):2028-37. doi: 10.1200/J・・・
著者: Roy A Patchell, Phillip A Tibbs, William F Regine, Richard Payne, Stephen Saris, Richard J Kryscio, Mohammed Mohiuddin, Byron Young
雑誌名: Lancet. 2005 Aug 20-26;366(9486):643-8. doi: 10.1016/S0140-6736(05)66954-1.
Abstract/Text BACKGROUND: The standard treatment for spinal cord compression caused by metastatic cancer is corticosteroids and radiotherapy. The role of surgery has not been established. We assessed the efficacy of direct decompressive surgery.
METHODS: In this randomised, multi-institutional, non-blinded trial, we randomly assigned patients with spinal cord compression caused by metastatic cancer to either surgery followed by radiotherapy (n=50) or radiotherapy alone (n=51). Radiotherapy for both treatment groups was given in ten 3 Gy fractions. The primary endpoint was the ability to walk. Secondary endpoints were urinary continence, muscle strength and functional status, the need for corticosteroids and opioid analgesics, and survival time. All analyses were by intention to treat.
FINDINGS: After an interim analysis the study was stopped because the criterion of a predetermined early stopping rule was met. Thus, 123 patients were assessed for eligibility before the study closed and 101 were randomised. Significantly more patients in the surgery group (42/50, 84%) than in the radiotherapy group (29/51, 57%) were able to walk after treatment (odds ratio 6.2 [95% CI 2.0-19.8] p=0.001). Patients treated with surgery also retained the ability to walk significantly longer than did those with radiotherapy alone (median 122 days vs 13 days, p=0.003). 32 patients entered the study unable to walk; significantly more patients in the surgery group regained the ability to walk than patients in the radiation group (10/16 [62%] vs 3/16 [19%], p=0.01). The need for corticosteroids and opioid analgesics was significantly reduced in the surgical group.
INTERPRETATION: Direct decompressive surgery plus postoperative radiotherapy is superior to treatment with radiotherapy alone for patients with spinal cord compression caused by metastatic cancer.

PMID 16112300  Lancet. 2005 Aug 20-26;366(9486):643-8. doi: 10.1016/S0・・・
著者: Xin Shelley Wang, Laurence D Rhines, Almon S Shiu, James N Yang, Ugur Selek, Ibrahima Gning, Ping Liu, Pamela K Allen, Syed S Azeem, Paul D Brown, Hadley J Sharp, David C Weksberg, Charles S Cleeland, Eric L Chang
雑誌名: Lancet Oncol. 2012 Apr;13(4):395-402. doi: 10.1016/S1470-2045(11)70384-9. Epub 2012 Jan 27.
Abstract/Text BACKGROUND: Spinal stereotactic body radiation therapy (SBRT) is increasingly used to manage spinal metastases, yet the technique's effectiveness in controlling the symptom burden of spinal metastases has not been well described. We investigated the clinical benefit of SBRT for managing spinal metastases and reducing cancer-related symptoms.
METHODS: 149 patients with mechanically stable, non-cord-compressing spinal metastases (166 lesions) were given SBRT in a phase 1-2 study. Patients received a total dose of 27-30 Gy, typically in three fractions. Symptoms were measured before SBRT and at several time points up to 6 months after treatment, by the Brief Pain Inventory (BPI) and the M D Anderson Symptom Inventory (MDASI). The primary endpoint was frequency and duration of complete pain relief. The study is completed and is registered with ClinicalTrials.gov, number NCT00508443.
FINDINGS: Median follow-up was 15·9 months (IQR 9·5-30·3). The number of patients reporting no pain from bone metastases, as measured by the BPI, increased from 39 of 149 (26%) before SBRT to 55 of 102 (54%) 6 months after SBRT (p<0·0001). BPI-reported pain reduction from baseline to 4 weeks after SBRT was clinically meaningful (mean 3·4 [SD 2·9] on the BPI pain-at-its-worst item at baseline, 2·1 [2·4] at 4 weeks; effect size 0·47, p=0·00076). These improvements were accompanied by significant reduction in opioid use during the first 6 months after SBRT (43 [28·9%] of 149 patients with strong opioid use at baseline vs 20 [20·0%] of 100 at 6 months; p=0·011). Ordinal regression modelling showed that patients reported significant pain reduction according to the MDASI during the first 6 months after SBRT (p=0·00003), and significant reductions in a composite score of the six MDASI symptom interference with daily life items (p=0·0066). Only a few instances of non-neurological grade 3 toxicities occurred: nausea (one event), vomiting (one), diarrhoea (one), fatigue (one), dysphagia (one), neck pain (one), and diaphoresis (one); pain associated with severe tongue oedema and trismus occurred twice; and non-cardiac chest pain was reported three times. No grade 4 toxicities occurred. Progression-free survival after SBRT was 80·5% (95% CI 72·9-86·1) at 1 year and 72·4% (63·1-79·7) at 2 years.
INTERPRETATION: SBRT is an effective primary or salvage treatment for mechanically stable spinal metastasis. Significant reductions in patient-reported pain and other symptoms were evident 6 months after SBRT, along with satisfactory progression-free survival and no late spinal cord toxicities.
FUNDING: National Cancer Institute of the US National Institutes of Health.

Copyright © 2012 Elsevier Ltd. All rights reserved.
PMID 22285199  Lancet Oncol. 2012 Apr;13(4):395-402. doi: 10.1016/S147・・・
著者: R F Young, E M Post, G A King
雑誌名: J Neurosurg. 1980 Dec;53(6):741-8. doi: 10.3171/jns.1980.53.6.0741.
Abstract/Text Metastases to the spinal epidural space with compression of the spinal cord or cauda equina are commonly encountered by physicians in a variety of clinical field. In the recent past, decompressive laminectomy followed by radiotheray was thought to be the best available treatment. More recently, radiotherapy alone has been advocated as an alternative treatment mode with a similar rate of effectiveness. This study compares laminectomy followed by radiotherapy to radiotherapy alone in the treatment of spinal epidural metastases in a randomized, prospective clinical trial. No significant difference was found in the effectiveness of the two treatment methods in regard to pain relief, improved ambulation, or improved sphincter function. Patients with an incomplete myelographic block fared well regardless of treatment, and those with a complete block fared poorly. Because of the limited size of this study and because of certain unforeseen design defects, the results are suggestive but not conclusive. Suggestions are made for a future randomized, prospective multicenter study that would conclusively answer the perplexing question as to the most efficacious method for treating spinal epidural metastases.

PMID 7441333  J Neurosurg. 1980 Dec;53(6):741-8. doi: 10.3171/jns.198・・・
著者: Paul Klimo, Clinton J Thompson, John R W Kestle, Meic H Schmidt
雑誌名: Neuro Oncol. 2005 Jan;7(1):64-76. doi: 10.1215/S1152851704000262.
Abstract/Text Radiotherapy has been the primary therapy for managing metastatic spinal disease; however, surgery that decompresses the spinal cord circumferentially, followed by reconstruction and immediate stabilization, has also proven effective. We provide a quantitative comparison between the "new" surgery and radiotherapy, based on articles that report on ambulatory status before and after treatment, age, sex, primary neoplasm pathology, and spinal disease distribution. Ambulation was categorized as "success" or "rescue" (proportion of patients ambulatory after treatment and proportion regaining ambulatory function, respectively). Secondary outcomes were also analyzed. We calculated cumulative success and rescue rates for our ambulatory measurements and quantified heterogeneity using a mixed-effects model. We investigated the source of the heterogeneity in both a univariate and multivariate manner with a meta-regression model. Our analysis included data from 24 surgical articles (999 patients) and 4 radiation articles (543 patients), mostly uncontrolled cohort studies (Class III). Surgical patients were 1.3 times more likely to be ambulatory after treatment and twice as likely to regain ambulatory function. Overall ambulatory success rates for surgery and radiation were 85% and 64%, respectively. Primary pathology was the principal factor determining survival. We present the first known formal meta-analysis using data from nonrandomized clinical studies. Although we attempted to control for imbalances between the surgical and radiation groups, significant heterogeneity undoubtedly still exists. Nonetheless, we believe the differences in the outcomes indicate a true difference resulting from treatment. We conclude that surgery should usually be the primary treatment with radiation given as adjuvant therapy. Neurologic status, overall health, extent of disease (spinal and extraspinal), and primary pathology all impact proper treatment selection.

PMID 15701283  Neuro Oncol. 2005 Jan;7(1):64-76. doi: 10.1215/S1152851・・・
著者: Jaehon M Kim, Elena Losina, Christopher M Bono, Andrew J Schoenfeld, Jamie E Collins, Jeffrey N Katz, Mitchel B Harris
雑誌名: Spine (Phila Pa 1976). 2012 Jan 1;37(1):78-84. doi: 10.1097/BRS.0b013e318223b9b6.
Abstract/Text STUDY DESIGN: Systematic literature review from 1970 to 2007.
OBJECTIVE: This study reports the results of a systematic review comparing surgical decompression ± radiation to radiation therapy alone among patients with metastatic spinal cord compression.
SUMMARY OF BACKGROUND DATA: Currently, the optimal treatment of metastatic spine lesions is not well defined and is inconsistent. Radiation and surgical excision are both accepted and effective. There appears to be a favorable trend for improved neurological outcome with surgical excision and stabilization as part of the management.
METHODS: A review of the English literature from 1970 to 2007 was performed in the Medline database using general MeSH terms. Relevant outcome studies for the treatment of metastatic spinal cord compression were selected through criteria defined a priori. The primary outcome was ambulatory capacity. A random effects model was built to compare results between treatment groups, based on calculated proportions from each study.
RESULTS: Of the 1595 articles screened, 33 studies (2495 patients) were selected based on our inclusion and exclusion criteria. Sixty-four percent of the patients who underwent surgical decompression, tumor excision, and stabilization had neurological improvement from nonambulatory to ambulatory status. Twenty-nine percent of the radiation therapy group regained the ability to ambulate after treatment (P < 0.001). Paraplegic patients had a 4-fold greater recovery rate to functional ambulation with surgical intervention than with radiation therapy alone (42% vs. 10%, P < 0.001). Pain relief was noted in 88% of the patients in the surgical studies and in 74% of the patients in studies of radiation therapy (P < 0.001). The overall surgical complication rate was 29%.
CONCLUSION: This systematic review suggests that surgical excision of tumor and instrumented stabilization may improve clinical outcomes compared with radiation therapy alone, with regard to neurological function and pain. However, most data in the current literature are from observational studies, where variations in patient population and treatments cannot be controlled. This compromised our ability to compare the results of both treatments directly.

PMID 21629164  Spine (Phila Pa 1976). 2012 Jan 1;37(1):78-84. doi: 10.・・・
著者: Michael G Fehlings, Anick Nater, Lindsay Tetreault, Branko Kopjar, Paul Arnold, Mark Dekutoski, Joel Finkelstein, Charles Fisher, John France, Ziya Gokaslan, Eric Massicotte, Laurence Rhines, Peter Rose, Arjun Sahgal, James Schuster, Alexander Vaccaro
雑誌名: J Clin Oncol. 2016 Jan 20;34(3):268-76. doi: 10.1200/JCO.2015.61.9338. Epub 2015 Nov 23.
Abstract/Text PURPOSE: Although surgery is used increasingly as a strategy to complement treatment with radiation and chemotherapy in patients with metastatic epidural spinal cord compression (MESCC), the impact of surgery on health-related quality of life (HRQoL) is not well established. We aimed to prospectively evaluate survival, neurologic, functional, and HRQoL outcomes in patients with MESCC who underwent surgical management.
PATIENTS AND METHODS: One hundred forty-two patients with a single symptomatic MESCC lesion who were treated surgically were enrolled onto a prospective North American multicenter study and were observed at least up to 12 months. Clinical data, including Brief Pain Inventory, ASIA (American Spinal Injury Association) impairment scale, SF-36 Short Form Health Survey, Oswestry Disability Index, and EuroQol 5 dimensions (EQ-5D) scores, were obtained preoperatively, and at 6 weeks and 3, 6, 9, and 12 months postoperatively.
RESULTS: Median survival time was 7.7 months. The 30-day and 12-month mortality rates were 9% and 62%, respectively. There was improvement at 6 months postoperatively for ambulatory status (McNemar test, P < .001), lower extremity and total motor scores (Wilcoxon signed rank test, P < .001), and at 6 weeks and 3, 6, and 12 months for Oswestry Disability Index, EQ-5D, and pain interference (paired t test, P < .013). Moreover, at 3 months after surgery, the ASIA impairment scale grade was improved (Stuart-Maxwell test P = .004). SF-36 scores improved postoperatively in six of eight scales. The incidence of wound complications was 10% and 2 patients required a second surgery (screw malposition and epidural hematoma).
CONCLUSION: Surgical intervention, as an adjunct to radiation and chemotherapy, provides immediate and sustained improvement in pain, neurologic, functional, and HRQoL outcomes, with acceptable risks in patients with a focal symptomatic MESCC lesion who have at least a 3 month survival prognosis.

© 2015 by American Society of Clinical Oncology.
PMID 26598751  J Clin Oncol. 2016 Jan 20;34(3):268-76. doi: 10.1200/JC・・・
著者: Dirk Rades, Stefan Huttenlocher, Juergen Dunst, Amira Bajrovic, Johann H Karstens, Volker Rudat, Steven E Schild
雑誌名: J Clin Oncol. 2010 Aug 1;28(22):3597-604. doi: 10.1200/JCO.2010.28.5635. Epub 2010 Jul 6.
Abstract/Text PURPOSE: The appropriate treatment for MSCC is controversial. A small randomized trial showed that decompressive surgery followed by radiotherapy was superior to radiotherapy alone. That study was limited to highly selected patients. Additional studies comparing surgery plus radiotherapy to radiotherapy could better clarify the role of surgery.
METHODS: Data from 108 patients receiving surgery plus radiotherapy were matched to 216 patients (1:2) receiving radiotherapy alone. Groups were matched for 11 potential prognostic factors and compared for post-treatment motor function, ambulatory status, regaining ambulatory status, local control, and survival. Subgroup analyses were performed for patients receiving adequate surgery (direct decompressive surgery plus stabilization of involved vertebrae), patients receiving laminectomy, patients with solid tumors, patients with solid tumors receiving adequate surgery, and patients with solid tumors receiving laminectomy.
RESULTS: Improvement of motor function occurred in 27% of patients after surgery plus radiotherapy and 26% after radiotherapy alone (P = .92). Post-treatment ambulatory rates were 69% after surgery plus radiotherapy and 68% after radiotherapy alone (P = .99). Of the nonambulatory patients, 30% and 26%, respectively, (P = .86) regained ambulatory status after treatment. One-year local control rates were 90% after surgery plus radiotherapy and 91% after radiotherapy alone (P = .48). One-year overall survival rates were 47% and 40%, respectively (P = .50). The subgroup analyses did not show significant differences between both groups. Surgery-related complications occurred in 11% of patients.
CONCLUSION: In this study, the outcomes of the end points evaluated after radiotherapy alone appeared similar to those of surgery plus radiotherapy. A new randomized trial comparing both treatments is justified.

PMID 20606090  J Clin Oncol. 2010 Aug 1;28(22):3597-604. doi: 10.1200/・・・
著者: Daryl R Fourney, Evan M Frangou, Timothy C Ryken, Christian P Dipaola, Christopher I Shaffrey, Sigurd H Berven, Mark H Bilsky, James S Harrop, Michael G Fehlings, Stefano Boriani, Dean Chou, Meic H Schmidt, David W Polly, Roberto Biagini, Shane Burch, Mark B Dekutoski, Aruna Ganju, Peter C Gerszten, Ziya L Gokaslan, Michael W Groff, Norbert J Liebsch, Ehud Mendel, Scott H Okuno, Shreyaskumar Patel, Laurence D Rhines, Peter S Rose, Daniel M Sciubba, Narayan Sundaresan, Katsuro Tomita, Peter P Varga, Luiz R Vialle, Frank D Vrionis, Yoshiya Yamada, Charles G Fisher
雑誌名: J Clin Oncol. 2011 Aug 1;29(22):3072-7. doi: 10.1200/JCO.2010.34.3897. Epub 2011 Jun 27.
Abstract/Text PURPOSE: Standardized indications for treatment of tumor-related spinal instability are hampered by the lack of a valid and reliable classification system. The objective of this study was to determine the interobserver reliability, intraobserver reliability, and predictive validity of the Spinal Instability Neoplastic Score (SINS).
METHODS: Clinical and radiographic data from 30 patients with spinal tumors were classified as stable, potentially unstable, and unstable by members of the Spine Oncology Study Group. The median category for each patient case (consensus opinion) was used as the gold standard for predictive validity testing. On two occasions at least 6 weeks apart, each rater also scored each patient using SINS. Each total score was converted into a three-category data field, with 0 to 6 as stable, 7 to 12 as potentially unstable, and 13 to 18 as unstable.
RESULTS: The κ statistics for interobserver reliability were 0.790, 0.841, 0.244, 0.456, 0.462, and 0.492 for the fields of location, pain, bone quality, alignment, vertebral body collapse, and posterolateral involvement, respectively. The κ statistics for intraobserver reliability were 0.806, 0.859, 0.528, 0.614, 0.590, and 0.662 for the same respective fields. Intraclass correlation coefficients for inter- and intraobserver reliability of total SINS score were 0.846 (95% CI, 0.773 to 0.911) and 0.886 (95% CI, 0.868 to 0.902), respectively. The κ statistic for predictive validity was 0.712 (95% CI, 0.676 to 0.766).
CONCLUSION: SINS demonstrated near-perfect inter- and intraobserver reliability in determining three clinically relevant categories of stability. The sensitivity and specificity of SINS for potentially unstable or unstable lesions were 95.7% and 79.5%, respectively.

PMID 21709187  J Clin Oncol. 2011 Aug 1;29(22):3072-7. doi: 10.1200/JC・・・
著者: Yasuaki Tokuhashi, Hiromi Matsuzaki, Hiroshi Oda, Masashi Oshima, Junnosuke Ryu
雑誌名: Spine (Phila Pa 1976). 2005 Oct 1;30(19):2186-91.
Abstract/Text STUDY DESIGN: A semi-prospective clinical study was conducted.
OBJECTIVES: To evaluate the accuracy of a revised scoring system predicting metastatic spinal tumor prognosis and the suitability of the subsequent treatment strategy.
SUMMARY OF THE BACKGROUND DATA: We used a scoring system for the preoperative evaluation of the prognosis of metastatic spinal tumors and selected treatment methods for the predicted prognosis. In the previous version of our scoring system, the reliability of the predicting prognosis was 63.3% in 128 patients with metastatic spinal tumors.
METHODS: The study participants were 164 patients who died after surgery and 82 who died after conservative treatment. Six parameters were used in the revised scoring system. Each parameter ranged from 0 to 5 points, and the total score was 15 points. In principle, conservative treatment or palliative procedures were indicated in patients with a total score of 8 or less (predicted survival period, less than 6 months) or those with multiple vertebral metastases, while excisional procedures were performed in patients with a total score of 12 or more (predicted survival period, 1 year or more) or those with a total score of 9 to 11 (predicted survival period, 6 months or more) and with metastasis in a single vertebra. The selection of treatment modality was followed faithfully according to the criteria of the revised scoring system after 1998. The prognosis predicted by the revised scoring system and the actual survival period after treatment were compared, and the reliability of the prognostic criteria was analyzed for the group subjected to it prospectively after 1998 (n = 118) and for all 246 patients it was applied to retrospectively.
RESULTS: The total score for each patient could be correlated with the survival period. This correlation was also observed in each treatment group. The consistency rate between the predicted prognosis from the criteria of the total scores and the actual survival period was high in patients within each score range (0-8, 9-11, or 12-15), 86.4% in the 118 patients evaluated prospectively after 1998, and 82.5% in the 246 patients evaluated retrospectively. Furthermore, a similar result was also observed in both the surgical procedure group and conservative treatment group. The rate of consistency between the predicted prognosis and the actual survival period in each local extension of the lesion was 75% or more in all types, excluding Type 6 in the surgical classification of Tomita et al.
CONCLUSION: The prognostic criteria using the total scores from our revised scoring system were useful for the pretreatment evaluation of metastatic spinal tumor prognosis irrespective of treatment modality or local extension of the lesion.

PMID 16205345  Spine (Phila Pa 1976). 2005 Oct 1;30(19):2186-91.
著者: Aditya V Karhade, Quirina C B S Thio, Paul T Ogink, Christopher M Bono, Marco L Ferrone, Kevin S Oh, Philip J Saylor, Andrew J Schoenfeld, John H Shin, Mitchel B Harris, Joseph H Schwab
雑誌名: Neurosurgery. 2019 Oct 1;85(4):E671-E681. doi: 10.1093/neuros/nyz070.
Abstract/Text BACKGROUND: Increasing prevalence of metastatic disease has been accompanied by increasing rates of surgical intervention. Current tools have poor to fair predictive performance for intermediate (90-d) and long-term (1-yr) mortality.
OBJECTIVE: To develop predictive algorithms for spinal metastatic disease at these time points and to provide patient-specific explanations of the predictions generated by these algorithms.
METHODS: Retrospective review was conducted at 2 large academic medical centers to identify patients undergoing initial operative management for spinal metastatic disease between January 2000 and December 2016. Five models (penalized logistic regression, random forest, stochastic gradient boosting, neural network, and support vector machine) were developed to predict 90-d and 1-yr mortality.
RESULTS: Overall, 732 patients were identified with 90-d and 1-yr mortality rates of 181 (25.1%) and 385 (54.3%), respectively. The stochastic gradient boosting algorithm had the best performance for 90-d mortality and 1-yr mortality. On global variable importance assessment, albumin, primary tumor histology, and performance status were the 3 most important predictors of 90-d mortality. The final models were incorporated into an open access web application able to provide predictions as well as patient-specific explanations of the results generated by the algorithms. The application can be found at https://sorg-apps.shinyapps.io/spinemetssurvival/.
CONCLUSION: Preoperative estimation of 90-d and 1-yr mortality was achieved with assessment of more flexible modeling techniques such as machine learning. Integration of these models into applications and patient-centered explanations of predictions represent opportunities for incorporation into healthcare systems as decision tools in the future.

Copyright © 2019 by the Congress of Neurological Surgeons.
PMID 30869143  Neurosurgery. 2019 Oct 1;85(4):E671-E681. doi: 10.1093/・・・
著者: Christian Grommes, George J Bosl, Lisa M DeAngelis
雑誌名: Cancer. 2011 May 1;117(9):1911-6. doi: 10.1002/cncr.25693. Epub 2010 Nov 29.
Abstract/Text BACKGROUND: Germ cell tumors (GCTs) are chemosensitive, and epidural spinal cord compression (ESCC) from GCT may be amenable to treatment with chemotherapy (CT) only. This retrospective study compares the clinical outcome of GCT patients with ESCC treated with CT or radiotherapy (RT) + CT.
METHODS: All patients with a histologic diagnosis of GCT from 1984 to 2009 were included in this study. Patients with ESCC were identified. Age, clinical features, histology, treatment, and outcome were analyzed.
RESULTS: The authors identified 1734 patients with GCT, of whom 29 (1.7%) had ESCC. The median age of these 29 patients was 32 years. The ESCC was treated with CT only in 16, RT + CT in 11, and 2 patients received palliative care only. The ESCC was more extensive in the RT + CT than the CT group. Patients who received RT + CT had a higher proportion of failed prior CT regimens, a higher percentage of nonseminomatous GCT, T-spine involvement, multilevel epidural disease, and bony vertebral metastases. Median overall survival after diagnosis of ESCC was not reached for those treated with CT alone versus 15 months for those receiving RT + CT (P = .02). There was also a significant difference in survival in patients receiving first-line therapy (n = 15), where median overall survival was not reached in the CT group (n = 11), compared with 22 months in the RT group (n = 4) (P = .04).
CONCLUSIONS: GCTs rarely involve the epidural compartment. Patients with ESCC who are likely to have chemosensitive disease can receive CT alone as definitive treatment.

Copyright © 2010 American Cancer Society.
PMID 21509768  Cancer. 2011 May 1;117(9):1911-6. doi: 10.1002/cncr.256・・・
著者: I Sasagawa, H Gotoh, H Miyabayashi, O Yamaguchi, Y Shiraiwa
雑誌名: Int Urol Nephrol. 1991;23(4):351-6.
Abstract/Text The authors describe 2 cases of symptomatic spinal cord compression due to metastatic prostatic cancer. Both cases showed marked improvement of cord compression after hormone therapy, and decompressive laminectomy was not necessary. The management of prostatic cancer patients with symptomatic spinal cord compression is discussed.

PMID 1938231  Int Urol Nephrol. 1991;23(4):351-6.

ページ上部に戻る

戻る

さらなるご利用にはご登録が必要です。

こちらよりご契約または優待日間無料トライアルお申込みをお願いします。

(※トライアルご登録は1名様につき、一度となります)


ご契約の場合はご招待された方だけのご優待特典があります。

以下の優待コードを入力いただくと、

契約期間が通常12ヵ月のところ、14ヵ月ご利用いただけます。

優待コード: (利用期限:まで)

ご契約はこちらから