今日の臨床サポート

転移性脊椎腫瘍

著者: 村上英樹 名古屋市立大学病院 整形外科

監修: 酒井昭典 産業医科大学 整形外科学教室

著者校正/監修レビュー済:2022/03/16
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
患者向け説明資料

概要・推奨   

  1. がんの既往のある患者が脊椎に痛みを訴えた場合、転移性脊椎腫瘍を念頭に置くことが推奨される(推奨度1)
  1. 転移性脊椎腫瘍を疑った場合、全身の造影CTを撮影することが推奨される(推奨度1)
  1. 転移性脊椎腫瘍と診断した場合、余命を評価することが推奨される(推奨度1)
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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。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※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、実際の保険適応の査定において保険適応及び保険適応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応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:
村上英樹 : 講演料(大正製薬)[2022年]
監修:酒井昭典 : 特に申告事項無し[2022年]

改訂のポイント:
  1.  定期レビューを行い、細かな文言修正・追記などを行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 転移性脊椎腫瘍とは、悪性腫瘍が脊椎に転移した腫瘍性疾患である。
  1. 骨は肺、肝臓に次ぐがん転移の好発部位であり、骨転移のなかで脊椎は最も転移しやすい部位である。
  1. 骨転移を起こす頻度の高いがんは、乳癌、前立腺癌、肺癌、甲状腺癌、腎癌である。腫瘍による骨破壊が起きると脊柱の支持性が失われ、転移部位に応じて首や背中、腰の疼痛が生じる。
  1. 最近の分子標的治療などのがん治療の急速な進歩により、がん患者の生命予後が格段に改善してきており、今後は脊椎転移の患者が急増してきている。
  1. 転移性脊椎腫瘍は痛みと麻痺を引き起こし、ADLを著しく障害する。
問診・診察のポイント  
問診:
  1. 痛みの発症時期と程度を確認する。

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文献 

Yasuaki Tokuhashi, Yasumitsu Ajiro, Natsuki Umezawa
Outcome of treatment for spinal metastases using scoring system for preoperative evaluation of prognosis.
Spine (Phila Pa 1976). 2009 Jan 1;34(1):69-73. doi: 10.1097/BRS.0b013e3181913f19.
Abstract/Text STUDY DESIGN: Prospective study.
OBJECTIVE: To evaluate our treatment outcome for spinal metastases using our treatment strategy based on prognostic scoring system.
SUMMARY OF BACKGROUND DATA: In the treatment of spinal metastases, life expectancy is most important, and our scoring system for metastatic spine tumor prognosis has been useful for such prognostic evaluation.
METHODS: Conservative treatment or palliative surgery was indicated in patients with a predicted prognosis of less than 6 months or in those with multiple vertebral metastases, whereas excisional surgery was performed in patients with a predicated prognosis of 1 year or more, or with a predicted prognosis of 6 months or more, and with metastasis in a single vertebra. One hundred eighty-three patients were prospectively treated according to this principle using our prognostic scoring system, and the outcome was evaluated.
RESULTS: The consistency rate between the predicted prognosis from the criteria of the scoring system and the actual survival period was high in patients within each score range (0-8, 9-11, or 12-15), 87.9% in the 183 patients. Only the palliative surgery group (n = 55) showed a significant improvement of the Barthel index between before and after treatment (P < 0.01). The mean maximum Barthel index after treatment in any modality ran parallel to the total scores of our scoring system.
CONCLUSION: The prognostic criteria using our scoring system were useful for the pretreatment evaluation of prognosis irrespective of the treatment modality. In any treatment, the survival period of the patients affected the functional prognosis; therefore, it may be appropriate and realistic to select treatment methods by giving first priority to the life expectancy of patients.

PMID 19127163
Henrik Bauer, Katsuro Tomita, Norio Kawahara, Mohamed E Abdel-Wanis, Hideki Murakami
Surgical strategy for spinal metastases.
Spine (Phila Pa 1976). 2002 May 15;27(10):1124-6.
Abstract/Text
PMID 12004183
K Tomita, N Kawahara, H Baba, H Tsuchiya, S Nagata, Y Toribatake
Total en bloc spondylectomy for solitary spinal metastases.
Int Orthop. 1994 Oct;18(5):291-8.
Abstract/Text We have developed a technique for total en bloc spondylectomy through a posterior approach and now report our experience of 20 patients with a solitary or localised metastasis in the thoracic or lumbar vertebrae. There are two steps: an en bloc laminectomy, followed by en bloc resection of the vertebral body with an oncological wide margin and the insertion of a vertebral prosthesis. Pain was relieved in the 17 patients who could be assessed; 11 of the 15 patients with a neurological deficit were much improved, impending paralysis being prevented in 5 patients. There have been no local recurrences. Nine patients are at present alive with a mean follow up of 17.4 months.

PMID 7852009
Katsuro Tomita, Norio Kawahara, Hideki Murakami, Satoru Demura
Total en bloc spondylectomy for spinal tumors: improvement of the technique and its associated basic background.
J Orthop Sci. 2006 Jan;11(1):3-12. doi: 10.1007/s00776-005-0964-y.
Abstract/Text
PMID 16437342
Norio Kawahara, Katsuro Tomita, Hideki Murakami, Satoru Demura
Total en bloc spondylectomy for spinal tumors: surgical techniques and related basic background.
Orthop Clin North Am. 2009 Jan;40(1):47-63, vi. doi: 10.1016/j.ocl.2008.09.004.
Abstract/Text The authors' group has developed a new surgical technique of spondylectomy (vertebrectomy) called "total en bloc spondylectomy" (TES). This technique is different from spondylectomy in that it involves en bloc removal of the lesion, that is, removal of the whole vertebra, body and lamina, as one compartment. The surgical technique of TES has been remarkably improved based on adequate knowledge and consideration of the surgical anatomy, physiology, and biomechanics of the spine and spinal cord. Review of the developmental process of this operation leads to recognition of the tips, pitfalls, and solutions.

PMID 19064055
Hideki Murakami, Satoru Demura, Satoshi Kato, Hideji Nishida, Katsuhito Yoshioka, Hiroyuki Hayashi, Kei Inoue, Takashi Ota, Kazuya Shinmura, Noriaki Yokogawa, Xiang Fang, Hiroyuki Tsuchiya
Increase of IL-12 following reconstruction for total en bloc spondylectomy using frozen autografts treated with liquid nitrogen.
PLoS One. 2013;8(5):e64818. doi: 10.1371/journal.pone.0064818. Epub 2013 May 29.
Abstract/Text BACKGROUND: Total en bloc spondylectomy (TES) is a surgery designed to achieve complete resection of a malignant spinal tumor such as spinal metastasis. Although this procedure decreases the rate of local recurrence, it is questionable whether local control prolongs patient's survival. We developed a "second-generation TES" that brings about TES enhancing antitumor immunity to prolong patient's survival. Our purpose is to present a second-generation TES applied tumor-induced cryoimmunology and assess the immunity-enhancing effect after implementing this surgery.
METHODS: We performed a retrospective review of prospectively collected data in second-generation TES as carried out in 56 cases. In second-generation TES, instead of harvesting autograft from the ilium or fibula, the resected lamina and vertebral body from TES are frozen using liquid nitrogen and used as grafted bone for spinal reconstruction. In recent 26 of the 56 cases, in addition to the TES procedure, a small amount of the tumor tissue from the resected tumor-bearing vertebra was also placed into liquid nitrogen. This small amount of tumor tissue was then implanted subcutaneously on one side of the axilla. In 52 of 56 cases, measurement of interleukin 12 (IL-12) was performed before surgery and at both 1 and 3 months after surgery.
RESULTS: IL-12 increased after TES surgery in 38 of 52 cases (73.1%). The mean IL-12 relative concentrations at both 1 and 3 months after surgery, as compared to before surgery, were significantly higher (121±89 and 149±111%: P<0.05 and P<0.01).
CONCLUSIONS: Our results show that second-generation TES may provide not only a local radical cure but also a systemic immunological enhancement. Further prolonged survival in patients with a malignant spinal tumor is promising by second-generation TES.

PMID 23734222
Hideki Murakami, Satoshi Kato, Satoru Demura, Katsuhito Yoshioka, Hiroyuki Hayashi, Kei Inoue, Takashi Ota, Kazuya Shinmura, Noriaki Yokogawa, Xiang Fang, Hiroyuki Tsuchiya
Novel reconstruction technique using a frozen tumor-bearing vertebra from a total en bloc sponydylectomy for spinal tumors.
Orthopedics. 2013 Aug;36(8):605-7. doi: 10.3928/01477447-20130724-04.
Abstract/Text This article describes a novel reconstruction technique using frozen tumor-bearing vertebrae in total en bloc spondylectomy for spinal tumors. Instead of harvesting autograft from the ilium or fibula, the resected lamina and vertebral body from the total en bloc spondylectomy are frozen in liquid nitrogen and used as grafted bone for spinal reconstruction. A retrospective review of 56 patients was undertaken. As a result of this review, it was determined that this technique has the benefits of no pain at the bone harvest site, shortened operative time, decreased blood loss, and an additional antitumor immune response.

Copyright 2013, SLACK Incorporated.
PMID 23937737
Hideki Murakami, Satoshi Kato, Yasuhiro Ueda, Yoshiyasu Fujimaki, Hiroyuki Tsuchiya
Reconstruction using a frozen tumor-bearing vertebra in total en bloc spondylectomy can enhance antitumor immunity.
Eur Spine J. 2014 May;23 Suppl 2:222-7. doi: 10.1007/s00586-013-3056-2. Epub 2013 Oct 5.
Abstract/Text PURPOSE: Distant metastases from thyroid carcinoma are successfully cured if they take up radioiodine ((131)I), are of small size, and located in the lungs. Bone metastases have the worst prognosis because (131)I therapy and external beam radiotherapy are less effective. Our propose here is to report a patient with solitary spinal metastasis and multiple lung metastases from thyroid carcinoma, whose spinal metastasis was treated by total en bloc spondylectomy (TES) enhancing antitumor immunity using frozen tumor-bearing bone for spinal reconstruction.
METHODS: The patient was a 37-year-old male who had solitary spinal metastasis at T4 and multiple lung metastases from thyroid carcinoma. (131)I therapy for the multiple lung metastases resulted in no effect because the apparent (131)I uptake was observed only in T4 metastasis. We performed a TES of T4 with cryotreatment. After en bloc excision of T4, the excised tumor-bearing vertebra was frozen by liquid nitrogen. In spinal reconstruction, the frozen vertebra was used in a mesh cage inserted into the anterior defect.
RESULTS: After surgery, the thyroglobulin level decreased without any other adjuvant therapy and the serum levels of INF-γ and IL-12 increased. This indicates antitumor immunity was activated. Then, (131)I therapy became effective to the lung metastases causing the tumors to decrease in size and number. Three years after surgery, progression in the lung metastases, other metastasis, and local recurrence have not been observed.
CONCLUSIONS: TES with cryotreatment as presented is a novel surgery which can enhance antitumor immunity against other visible or non-visible metastases.

PMID 24097232
Hideki Murakami, Satoru Demura, Satoshi Kato, Katsuhito Yoshioka, Hiroyuki Hayashi, Kei Inoue, Takashi Ota, Kazuya Shinmura, Noriaki Yokogawa, Xiang Fang, Hiroyuki Tsuchiya
Systemic antitumor immune response following reconstruction using frozen autografts for total en bloc spondylectomy.
Spine J. 2014 Aug 1;14(8):1567-71. doi: 10.1016/j.spinee.2013.09.030. Epub 2013 Oct 17.
Abstract/Text BACKGROUND CONTEXT: Total en bloc spondylectomy (TES) is a surgery designed to achieve complete resection of a malignant spinal tumor, such as spinal metastasis. Although this procedure decreases the rate of local recurrence, it is questionable whether local control prolongs a patient's survival. In cryosurgery, antitumor immunity is activated after percutaneous cryoablation of tumors. We applied this tumor-induced cryoimmunology to TES surgery and developed a "second-generation TES" that brings about TES enhancing antitumor immunity to prolong a patient's survival.
PURPOSE: To present a second-generation TES applied tumor-induced cryoimmunology and assess the immunity-enhancing effect after implementing this surgery.
STUDY DESIGN: This is a retrospective review of prospectively collected data.
PATIENT SAMPLE: The sample consisted of 65 consecutive patients who underwent second-generation TES.
OUTCOME MEASURES: Interferon gamma (IFN-γ) and interleukin-12 (IL-12) before surgery and at both 1 and 3 months after surgery was used to assess the immunity-enhancing effect.
METHODS: In second-generation TES, instead of harvesting autograft from the ilium or fibula, the resected lamina and vertebral body from TES are frozen using liquid nitrogen and used as grafted bone for spinal reconstruction. In the most recent 33 of the 65 cases, in addition to the TES procedure, a small amount of the tumor tissue from the resected tumor-bearing vertebra was also placed into liquid nitrogen. This small amount of tumor tissue was then implanted subcutaneously on one side of the axilla at the end of the TES surgery. In 60 of 65 cases, measurement of IFN-γ and IL-12 was performed.
RESULTS: IFN-γ increased after surgery in 45 (75%) of 60 cases. The mean IFN-γ relative concentrations at both 1 and 3 months after surgery, as compared with before surgery, were significantly higher (284%±596% and 275%±354%: p<.05). IL-12 increased after surgery in 44 (73.3%) of 60 cases. The mean IL-12 relative concentrations at both 1 and 3 months after surgery, as compared with before surgery, were significantly higher (277%±385% and 486%±1032%: p>.05 and p<.01) at 3 months. At final follow-up, 13 of the 65 patients died due to progression of metastases (mean 12.6 months after TES), 15 remained free from disease, and 36 patients were alive with disease.
CONCLUSIONS: The second-generation TES using frozen tumor-bearing autograft inside a cage affords three benefits: (1) no pain at the bone harvest site, (2) shortening of operation time, and (3) decrease of blood loss. Moreover, our results show that second-generation TES provides not only a local radical cure but also a systemic immunological enhancement.

Copyright © 2014 Elsevier Inc. All rights reserved.
PMID 24314768

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