高剂量容积旋转调强放射治疗脊柱转移瘤的疗效分析

Analysis on volume modulated arc therapy for spinal metastases

目的分析容积旋转调强放射治疗脊柱转移瘤的临床疗效。方法采用容积旋转调强放射治疗20例脊柱转移瘤患者，45—60Gy／15～20次，3Gy／次，1次／d；采用数字评分法（NRS）、语言模拟疼痛评分法（VRS）、生活质量骨转移量表（EORTCQLQ—BM22）评估患者放疗前至随访结束各个时间段的疼痛缓解和生活质量改善情况。脊髓神经功能采用Frankel分级评价。主要研究终点为疼痛完全缓解，次要研究终点为患者死亡。结果至随访结束，20例脊柱转移瘤患者无疼痛患者数由放疗前0／20例上升至10／14例，差异有统计学意义（t=20．24，P〈0．05）。患者NRS评分显示，放疗1和4周疼痛评分均低于放疗前，由（6．50±0．51）分下降至（4．30±0．47）分和（2．50±0．50）分，差异均有统计学意义（t=15．98、27．57，P〈0．05），止痛能维持至随访结束。疼痛缓解伴强阿片类止痛药使用的下降，放疗后6月内强阿片类止痛药使用人数由16／20例下降至6／18例，差异有统计学意义（t=8．46，P〈0．05）。EORTCQLQ．BM22生活质量评分显示放疗后患者在疼痛部位、程度和功能方面均较放疗前明显改善，总分由放疗前（46．50±1．50）分下降至（38．35±0．98）分，差异有统计学意义（t=21．51，P〈0．05），社会心理方面变化不大（P〉0．05）。放疗前脊髓神经功能缺陷的患者放疗后6个月脊髓神经功能均得到改善，未出现脊髓神经放射性损伤。所有患者中位生存时间为10个月。结论容积旋转调强放射治疗脊柱转移瘤能够明显减轻患者疼痛、显著改善机体功能，患者生活质量明显提高，无脊髓神经放射性损伤等晚期并发症的发生。

Objective To evaluate clinical effect of volume modulated arc therapy（VMAT） for spinal metastases. Methods Twenty patients with spinal metastases who had been treated with VMAT were chosen to participate in the study. The prescribed dose varied from 45 to 60 Gy within 15 -20 fractions, 3 Gy per fraction, and one fraction per day of VMAT. Pain and quality of life were measured before VMAT and at several time points up to 6 months after treatment, by the numerical rating scale （NRS） and verbal rating scale （VRS） and the quality of life scale for bone metastases （EORTC QLQ- BM22） questionnaire. In addition, Frankel grading was used to evaluate the neurological function of spinal cord. The primary endpoint was frequency and duration of complete pain relief, and the secondary endpoint was death. Results At the end of the follow-up, the number of patients reporting no pain from spinal metastases, as measured by the NRS, increased from 0 of 20 before VMAT to 10 of 14 （t = 20.24, P 〈 0. 05）. NRS-reported pain reduction from baseline to 1 weeks and 4 weeks after VMAT were clinically meaningful with NRS score （6.50 ±0.51 ） at baseline, （4.30 ± 0.47 ） at 1 week and（2.50 ± 0.50） at 4 weeks （ t = 15.98, 27.57, P 〈 0.05 ）. The pain reduction maintained until the end of the follow-up. These improvements were accompanied by significant reduction in opioid use during the first 6 months after VMAT （16 of 20 patients with strong opioid use at baseline vs. 6 of 18 at 6 months; t = 8.46, P 〈0.05）. According to EORTC QLQ-BM22 questionnaire, patients obtained significant improvement in pain location,severity, and function with the score （46.50 ±1.50）at baseline, （38.35 ± 0. 98 ） at 4 weeks （t = 21.51, P 〈 0.05 ）. However, no significant alleviation in social psychology was reported（ P 〉 0.05 ）. After VMAT, the patients who suffered from nerve function impairment recovered to different extent. No one had radiation-induced injury, such as radiation myelitis, radiation pneumonitis, etc. Median survival time was 10 month. Conclusions VMAT is a safe and effective treatment method for spinal metastases. Significant reductions in patient-reported pain were observed, along with nerve dysfunction improved. The patients＇ quality of life was significantly improved. VMAT has no late spinal cord toxicities.