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中华老年骨科与康复电子杂志 ›› 2025, Vol. 11 ›› Issue (02) : 87 -101. doi: 10.3877/cma.j.issn.2096-0263.2025.02.003

骨肿瘤

肾癌脊柱转移瘤手术疗效及预后因素分析报道:附系统综述
朱锴1, 李爽1, 刘艳成1, 张净宇1, 张宏1, 张洪亮1, 刘金伟1, 胡永成1,()   
  1. 1. 300211 天津大学天津医院(天津市天津医院)骨与软组织肿瘤科
  • 收稿日期:2024-09-27 出版日期:2025-04-05
  • 通信作者: 胡永成
  • 基金资助:
    天津市质量攻关项目计划(颈椎转移瘤手术决策模型的开发)

Surgical outcomes and prognostic factors for patients with spinal metastases from renal carcinoma: a retrospective study and a systematic review

Kai Zhu1, Shuang Li1, Yancheng Liu1, Jingyu Zhang1, Hong Zhang1, Hongliang Zhang1, Jinwei Liu1, Yongcheng Hu1,()   

  1. 1. Department of Bone and Soft Tissue Tumor Oncology,Tianjin Hospital,Tianjin University,Tianjin 300211,China
  • Received:2024-09-27 Published:2025-04-05
  • Corresponding author: Yongcheng Hu
引用本文:

朱锴, 李爽, 刘艳成, 张净宇, 张宏, 张洪亮, 刘金伟, 胡永成. 肾癌脊柱转移瘤手术疗效及预后因素分析报道:附系统综述[J/OL]. 中华老年骨科与康复电子杂志, 2025, 11(02): 87-101.

Kai Zhu, Shuang Li, Yancheng Liu, Jingyu Zhang, Hong Zhang, Hongliang Zhang, Jinwei Liu, Yongcheng Hu. Surgical outcomes and prognostic factors for patients with spinal metastases from renal carcinoma: a retrospective study and a systematic review[J/OL]. Chinese Journal of Geriatric Orthopaedics and Rehabilitation(Electronic Edition), 2025, 11(02): 87-101.

目的

探索肾癌脊柱转移瘤的手术效果及生存相关因素。

方法

回顾性分析2019年12月至2023年3月于天津市天津医院就诊的肾癌脊柱转移瘤患者,收集患者的一般资料、辅助检查结果、手术资料、KPS评分、疼痛NRS评分、脊髓功能Frankel分级、术后治疗措施、局部复发率、生存情况。通过Kaplan-Meier 法计算中位生存时间,并估算术后生存率。相关系统综述是于Pubmed、Embase 和Cochrane Library 数据库检索1964年至2023年10月12 日发表的关于肾癌脊柱转移瘤手术治疗的临床研究,对检索文献质量评价后进行描述性分析。

结果

回顾性分析共纳入16例患者,均为男性,平均年龄(62.0±9.5)岁。其中5例行TES,占31.25%(5/16例);9例行分块切除(Piecemeal)术,占56.25%(9/16例);2例行PVP,占12.5%(2/16例)。14例开放手术患者中行术前栓塞3例,占21.43%(3/14例),术中出血量为(1 707.19±1 512.14)ml。患者KPS 评分术前为(51.87±20.40)分,术后(64.38±27.80)分,虽有升高趋势,但差异无统计学意义(P=0.052);疼痛NRS评分术前(6.2±1.4)分,术后(2.5±2.0)分,差异具有统计学意义(P<0.001);术前Frankel 分级A 级2 例,C 级1 例,D 级7 例,E 级6 例;术后Frankel 分级A 级3 例,B级1例,D级3例,E级9例,差异无统计学意义(P=0.792)。中位随访时间23月,至末次随访时死亡8例,中位生存时间26.0(95%CI:3.0,20.1)月,术后1年、2年和3年OS分别为88%、63%和31%。系统综述中共检索到15项研究,共基于1 007例患者。其中6项研究发现手术可以有效缓解脊柱转移瘤患者疼痛,7项研究研究显示手术可以改善MESCC患者的神经功能。对于不同手术类型是否可以延长患者生存时间以及术前栓塞是否可以减少术中出血,不同研究所得出的观点不一致。患者术后中位OS跨度较大,为6~34.7月。多个研究证实内脏转移和多处骨转移是影响肾癌脊柱转移瘤患者生存的负面因素。

结论

手术可以有效缓解患者疼痛,利于患者脊髓损伤功能恢复。影响肾癌脊柱转移瘤患者总体生存的主要负面预后因素为存在内脏转移和多处骨转移。

Objective

To explore the outcomes of surgery and prognostic factors on survival in patients with spinal metastases secondary to renal carcinoma.

Methods

A retrospective analysis was performed on 16 patients with renal carcinoma spinal metastases who were undergone surgeries at Tianjin Hospital from December 2019 to March 2023. Clinical data, KPS score, NRS score, Frankel grade, postoperative treatment measures, local recurrence rate and survival status of the patients were collected. The median survival time and postoperative survival rates were estimated by Kaplan-Meier method.A systematic review was conducted by searching the PubMed, Embase, and Cochrane Library databases. The related clinical studies on surgical treatment of spinal metastases from renal carcinoma were collected from 1964 to October 12,2023.After evaluating the quality of the literatures,a descriptive analysis was performed.

Results

A total of 16 patients were included in the retrospective analysis,all of whom were male,with an average age of 62.0±9.5 years.Among all the patients, 5 underwent en bloc spondylectomy (TES) (31.25%), 9 underwent piecemeal resection(56.25%),and 2 underwent percutaneous vertebroplasty(PVP)(12.5%).Preoperative embolization was performed in 3 among the 14 patients who underwent open surgery(21.43%),and the mean intraoperative blood loss was 1 707.19±1 512.14 ml. The preoperative KPS score was 51.87±20.40 and significantly increased to 64.38±27.80 postoperatively(P=0.052).The preoperative NRS score was 6.2±1.4 and decreased to 2.5±2.0 postoperatively (P<0.001).There were 2 patients of Frankel Grade A, 1 patient of Grade C, 7 patients of Grade D and 6 patients of Grade E before surgery. Postoperatively, there were 3 patients of Grade A,1 patient of Grade B,3 patients of Grade D and 9 patients of Grade E,but without statistically significant difference (P=0.792). The median follow-up time was 23 months, with 8 deaths by the last followup. The median survival time was 26.0 months (95% CI: 3.0, 20.1), The overall survival rates at 1y, 2y and 3y were 88%、63 and 31% respectively.After screening, 15 studies were included in this systematic review involving a total of 1007 patients.Six studies found that surgery effectively relieved pain in patients with renal carcinoma spinal metastases, while seven studies demonstrated that surgery improved neurological function in patients with metastatic epidural spinal cord compression (MESCC). However, the conclusions on whether different surgical types could bring survival benefit and whether preoperative embolization could reduce intraoperative blood loss were conflicted. The postoperative median overall survival ranged from 6 to 34.7 months.Multiple studies confirmed that visceral and multiple bone metastases were negative prognostic factors affecting the survival of patients with renal carcinoma spinal metastases.

Conclusions

Surgery can effectively alleviate pain and facilitate the recovery of spinal cord function for the patients with renal carcinoma spinal metastases.The main negative prognostic factors affecting the overall survival are the presence of visceral metastasis and multiple bone metastases.

表1 肾癌脊柱转移瘤患者的基本资料
表2 肾癌脊柱转移瘤患者手术前后临床情况变化情况
表3 患者手术前后脊髓功能Frankel分级变化情况
图1 患者总体生存曲线。患者总体中位生存时间26个月,术后1年、2年和3年OS分别为88%、63%和31%
图2 文献筛选流程图
表4 15项关于肾癌脊柱转移瘤手术治疗效果的研究基线资料
作者/发表年份 研究时期 研究类型 患者数量 性别(女/男) 年龄(岁) 肾切除术(是/总例数) 同步转移(是/总例数) 内脏转移(是/总例数) NOS
KING,1991[20] 1982~1987 R 33 15/18 平均值(范围):55.2(22~72) 28/33 - - 5
JACKSON,2001[21] 1993.1~1999.4 R 79 16/63 平均值(范围):55(16~82) - 26/79 - 6
TATSUI,2014[23] 1993~2007 R 267 61/206 平均值(范围):58(15~86) - - - 7
BAKKER,2014[22] 2006.1~2013.7 R 21 - - - - - 5
HAN,2015[24] 2003~2012 R 30 5/25 平均值(范围):52.2(25~78) 22/30 8/30 - 7
PETTEYS,2016[26] 2000.1~2011.12 R 30 7/23 平均值(范围):57.6(29~79) - - 13/30 7
KATO,2016[25] 1995~2010 R 36 10/26 平均值:58.6 - 18/36 - 7
MOSELE,2017[27] 2006~2012 R 63 24/39 中位数(四分位数间距):59.5(46.2~73.4) - 48/63 51/63 7
PTASHNIKOV,2020[28] 2005~2016 R 100 24/76 中位数(范围):56(23~74) 87/100 66/100 50/100 6
SHANKAR,2020[29] 2010.1~2017.12 R 78 23/55 中位数:63.5 - 22/78 65/78 5
ZHAI,2021[32] 2009~2019 R 43 8/35 中位数(范围):58(45~82) 10/43 30/43 12/43 7
KATO,2021[30] 1995~2017 R 65 12/53 平均值(标准差):58.8(8.9) 65/65 30/65 - 7
PARK,2021[31] 2007~2020 R 44 14/30 中位数(范围):65(40~81) 29/44 - - 6
TERZI,2022[33] 2009.11~2019.4 R 69 20/49 平均值:62.6 - 26/69 28/69 7
LEI,2023[6] 2016.1~2021.12 R 49 11/38 平均值(标准差):55.18(10.039) 25/49 - - 6
表5 肾癌脊柱转移瘤相关研究的手术类型和术后辅助治疗情况
作者/发表年份 患者数量(手术次数) 手术类型(例数) 术前栓塞例数例数(占比) 术中失血量(平均值±标准差,ml) 术后化疗例数(占比) 术后放疗例数(占比) 术后靶免治疗例数(占比)
KING,1991 33(46) 内固定:29无内固定:4 14(42.4%) 2992±426 - - -
JACKSON,2001 79(107) 内固定:76无内固定:3 47(59.5%) 中位数(范围):2100(50~31000) - - -
BAKKER,2014 21 后外侧入路:10前外侧入路:8联合入路:3 21(100%) - - - -
HAN,2015 30 - 17(56.7%) 栓塞组:2305未栓塞组:2454 4(13.3%) 10(33.3%) 10(33.3%)
PETTEYS,2016 30 环形减压:21整块切除:3 24(80%) 3066±2785 - - -
KATO,2016 36 椎骨切除:35整块切除:1 - - - - 2(5.6%)
MOSELE,2017 63 整块切除:4广泛切除联合内固定:23经皮内固定未减压:36 - 平均值:2.5U - 42(66.7%) 63(100%)
PTASH -NIKOV,2020 100 病灶切除联合内固定:39减压联合内固定:61 - - - 23(23.0%) 26(26.0%)
SHANKAR,2020 78 减压:16减压联合内固定:62 49(63%) 栓塞组:800(范围:50~12000)未栓塞组:800(范围:50~5000) - - 49(62.8%)
KATO,2021 65 TES:57半椎体切除:8 - - - - 免疫治疗:24(36.9%)靶向治疗:25(38.4%)
PARK,2021 44 椎体切除:31后路减压:9椎板切除:4 24(54.5%) 栓塞组:1100(范围:100~8800)未栓塞组:700(范围:100~6350) 33(75.0%) 27(61.4%) -
TERZI,2022 69 微创手术:4姑息手术:7病损切除:50整块病灶切除:10 - - - - -
LEI,2023 49 TES:33分离手术:16 - - - 49(100%)
表6 术后并发症
表7 术后生存状况及预后相关因素
作者/发表年份 患者数量 生存时间(月) 1 年生存率 2 年生存率 3 年生存率 5年生存率 局部复发例数(复发率) 单变量分析相关因素 多变量回归分析相关因素
KING,1991 33 平均值(标准差):8.0(1.5) - - - - 16(48.5%) 术前Frankel分级 -
JACKSON,2001 79 中位数(范围):12.3m(1m~6.7y) - - - 15.30% 13(16.5%) 无显著相关因素 无显著相关因素
TATSUI,2014 267 中位数(95%CI):11.3(9.5~13.0) 47% 30% 20% 8% 41(15.4%) 肾癌Fuhrman分级(4 vs <4)术前神经功能障碍(yes vs no)颈椎受累(yes vs no)术前辅助治疗(yes vs no)脊柱转移灶数量(≥4 vs <4)手术并发症(yes vs no)仅脊柱转移(yes vs no)孤立性脊柱转移瘤(yes vs no)脊柱手术期间全身疾病进展(yesvs no) 肾癌Fuhrman 分级(4 vs <4)术前神经功能障碍(yes vs no)脊柱手术期间全身疾病进展(yesvs no)
BAKKER,2014 21 平均值(范围):6(1~25) - - - - - 颈椎受累治愈意图Frankel分级(C/D vs. E)Motzer中等或高风险年龄放疗 Motzer 中等或高风险
HAN,2015 30 平均值(范围):17.0(12~32) 90.00% 50.00% - - - 内脏转移Tomita评分(3-5/6-8)Tokuhashi评分(4-9/10-12)年龄 Tokuhashi 评分(4-9/10-12)
PETTEYS,2016 30 中位数(范围):11.4(1m~9.9y) - - - 10% 5(16.7%) 肾脏切除内脏转移脊柱外骨转移行走障碍神经功能障碍 -
KATO,2016 36 CSS:Median:130 - - CSS:77.8% CSS:69.1% 0(0%) 肝转移 -
表7 术后生存状况及预后相关因素
作者/发表年份 患者数量 生存时间(月) 1 年生存率 2 年生存率 3 年生存率 5年生存率 局部复发例数(复发率) 单变量分析相关因素 多变量回归分析相关因素
MOSELE,2017 63 中位数(IQR):15.8(6.8~34.6) 49.20% 31.74% 12.69% 6.34% 11(17.5%) 多发脊柱转移内脏转移病理性骨折神经功能障碍 内脏转移病理性骨折神经功能障碍
PTASH -NIKOV,2020 100 中位数(95%CI):22(17~29) - - 29.7% 12% 16(16.0%) - -
SHAN -KAR,2020 78 中位数(95%CI ):717d(526d-1109d) - - - - - KPS评分术后系统治疗 术后系统治疗
ZHAI,2021 43 中位数:24 - - - - - 肾癌MSKCC评分同步转移肾癌Fuhrman分级脊柱转移灶数量骨转移灶数量内脏转移整块切除术前功能状态(ECOG 3)肝转移 肾癌MSKCC评分脊柱转移灶数量内脏转移整块切除术前功能状态(ECOG 3)
KATO,2021 65 中位CSS:100 - - CSS:76.9% CSS:62.3% 4(6.4%) 多发脊柱转移转移灶不全切除淋巴结转移脊柱同步转移 肝转移多发脊柱转移转移灶不全切除
PARK,2021 44 中位数(范围):8(0.3~92) - - - - 更高的Tokuhashi评分脊髓功能ASIA E级
TERZI,2022 69 中位数(95%CI ):34.7(20.8~51.9) - - 中位数(95%CI ):31.2%(19.2%~44.1%) - Tokuhashi评分内脏转移和其它部位骨转移手术方式 多发脊柱转移
LEI,2023 49 中位数(95%CI ):12.04(9.71-14.37) 59.4±8.2 17.5±7 - - - 内脏转移HALP评分≤20.67术前Frankel分级:A-C肾癌AJCC分期:3或4 期WHO/ISUP分级更高术前KPS评分≤60ECOG评分更高多发脊柱转移分离手术 WHO/ISUP 分级更高ECOG 评分更高多发脊柱转移
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