Rolle der Chirurgie bei solitären Wirbelsäulenmetastasen

Zusammenfassung

Moderne onkologische Therapien insbesondere im Bereich der Immuntherapien und targeted Therapien konnten deutliche Fortschritte in Bezug auf die Lebenserwartung von Patienten mit disseminiertem Tumorleiden erzielen.

Die chirurgische Therapie solitärer spinaler Metastasen stellt hier eine besondere Herausforderung dar. Mit der Technik der sogenannten en bloc Spondylektomie wird seit vielen Jahren für ausgewählte solitäre Läsionen prognostisch günstiger Tumorbiologien das Ziel einer extraläsionalen Resektion und kurativen Behandlung verfolgt.

Nach heutiger Datenlage scheint der Nutzen jedoch limitiert und muss kritisch bewertet werden. Bei wenigen prognostisch günstigen Tumorentitäten wie dem Nierenzell- und Schilddrüsenkarzinom konnte in Studien mit niedriger Evidenz ein signifikanter Überlebensvorteil [1] [2] nachgewiesen werden. Entwicklungen, insbesondere der stereotaktischer Bestrahlungstechniken scheinen jedoch vergleichbare Ergebnisse hinsichtlich lokaler Tumorkontrolle und Gesamtüberleben zu erzielen, was zumindest im US-amerikanischen Raum dazu geführt hat, dass die en bloc Spondylektomie quasi nicht mehr für diese Indikation empfohlen oder durchgeführt wird, sondern die primäre Therapie in der Radiochirurgie liegt.

Die en bloc Spondylektomie könnte bei einem hochselektiven Patientengut in wenigen spezialisierten Zentren einen marginalen Stellenwert behalten. Die Entwicklung sollte primär jedoch nicht nur in Richtung Verbesserung operativer v.a. weniger invasiver Techniken, sondern in Richtung Verbesserung molekularer Diagnostik und Therapien (Strahlentherapie, Chemo-, Immun- und targeted Therapien) gehen.

Abstract

Modern oncological therapies, especially in the field of immunotherapies and targeted therapies, have achieved significant progress in terms of life expectancy in patients with disseminated tumor diseases.

The surgical therapy of solitary spinal metastases poses a particular challenge. With the technique of so-called en bloc spondylectomy, the goal of extralesional resection and curative treatment has been pursued for many years in selected solitary lesions with prognostically favorable tumor biologies.

However, according to current data, the benefit seems limited and must be critically evaluated. In a few prognostically favorable tumor entities, such as renal cell carcinoma and thyroid carcinoma, a significant survival benefit has been demonstrated in low-evidence studies [1] [2]. However, developments, particularly in stereotactic radiation techniques appear to achieve comparable results in terms of local tumor control and overall survival, which has led, at least in the U.S., to the virtual discontinuation of en bloc spondylectomy being recommended or performed for this indication, with radiosurgery as the primary treatment.

En bloc spondylectomy may retain a marginal role in a highly selective patient population in a few specialized centers. However, the development should primarily not go in the direction of improvement of surgical especially less invasive techniques, but in the direction of improvement of molecular diagnostics and therapies (radiotherapy, chemo-, immuno- and targeted therapies).

Schlüsselwörter

Solitäre spinale Metastasen - spinale Metastasenchirurgie - en bloc Spondylektomie (EBS) - totale en bloc Spondylektomie (TES) - Hybrid Therapie - Separation Surgery, Stereotactic Body Radiation Therapie (SBRT) - spinale stereotaktische Radiochirurgie (SSRS)

Keywords

Solitary spinal metastases - spinal metastases surgery - en bloc spondylectomy (EBS) - total en bloc spondylectomy (TES) - hybrid therapy - separation surgery - stereotactic body radiation therapy (SBRT) - spinal stereotactic radiosurgery (SSRS)

Publication History

Article published online:
14 November 2022

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