脊椎肿瘤整块切除术后复发的影响因素分析

Analysis of influencing factors of recurrence after en bloc spondylectomy of spinal tumors

目的探讨脊椎肿瘤整块切除术后患者的生存及肿瘤复发情况,并分析术后肿瘤复发的相关影响因素。方法本研究为回顾性病例系列研究。回顾性分析2006年12月至2022年6月于北京大学人民医院骨肿瘤科接受脊椎肿瘤整块切除术的101例患者资料。男性58例,女性43例,手术时年龄(38.2±15.8)岁(范围:10~79岁);随访时间(44.0±36.0)个月(范围:12~171个月)。其中复发患者25例,女性7例,男性18例;手术时年龄(34.8±16.3)岁(范围:12~66岁)。其中骨巨细胞瘤5例,骨肉瘤6例,脊索瘤1例,软骨肉瘤5例,未分化肉瘤1例,纤维肉瘤1例,尤文肉瘤2例,转移瘤3例,恶性骨巨细胞瘤1例。采用Kaplan-Meier曲线对整体及复发患者进行生存分析。采用分段回归模型对复发率随入院时间变化序列进行拟合,以分段函数折点为纳入因素分析的时间点。单因素及多因素分析均采用Logistic回归。结果脊椎肿瘤整块切除术后患者整体中位无复发生存期为161个月(95%CI:92个月至NA)。其中25例复发患者的术后中位无复发生存期为13个月(95%CI:12~27个月)。根据肿瘤恶性程度分组,转移性肿瘤的无复发生存期明显较短(P=0.007);根据手术切缘分组,R0组的无进展生存期明显优于R1、R2组(P<0.01)。根据分段回归模型,本研究中脊椎肿瘤整块切除的复发率随入院时间呈明显下降趋势,2009年前肿瘤复发率明显较高,2014年后肿瘤复发率趋于稳定。单因素分析结果显示手术切缘、入院时间是患者复发的影响因素。多因素分析结果显示,手术切缘是影响患者复发的独立影响因素。与R0切除相比,R1切除(OR=13.453,95%CI:2.897~97.941,P=0.002)和R2切除(OR=11.379,95%CI:2.658~79.429,P=0.003)的肿瘤复发率均较高。结论脊椎肿瘤整块切除术后肿瘤整体复发率较高,肿瘤手术切缘是影响肿瘤复发的独立影响因素。

Objectives To investigate the survival and tumor recurrence after en bloc spondylectomy of spinal tumor and analyze the risk factors of postoperative tumor recurrence.Methods This is a retrospective case series study.Data of 101 patients undergoing en bloc spondylectomy of spinal tumors in the Musculoskeletal Tumor Center,Peking University People′s Hospital from December 2006 to June 2022 were analyzed.There were 58 males and 43 females,aged(38.2±15.8)years(range:10 to 79 years)at the time of surgery;the follow-up time was(44.0±36.0)months(range:12 to 171 months).Among them,there were 25 relapsed patients,with 7 females and 18 males;aged(34.8±16.3)years(range:12 to 66 years)at the time of surgery.The types of tumors included 5 giant cell tumors of bone,6 osteosarcomas,1 chordoma,5 chondrosarcomas,1 undifferentiated sarcoma,1 fibrosarcoma,2 Ewing sarcomas,3 metastases and 1 malignant giant cell tumor of bone.Survival analysis of overall and relapsed patients were performed using the Kaplan-Meier curves.A segmented regression model was used to fit the sequence of recurrence rate changes over time since admission and identify change points for further analysis on risk factors.Univariate and multivariate Logistic regression analysis were performed to assess risk factors associated with recurrence rate;results from multivariate regression analysis were presented using a forest plot.Results The tumor recurrence rate after en bloc spondylectomy was 24.8%(25/101).The overall median recurrence-free survival after en bloc spondylectomy was 161 months(95%CI:92 months to NA).The median recurrence-free survival of recurrent patients was 13 months(95%CI:12 to 27 months).Regarding the classification based on tumor malignancy,and relapse-free survival of metastatic tumors was significantly shorter(P=0.007);and among the surgical margin groups,relapse-free survival of R0 group was significantly better than the R1 and R2 groups(P<0.01).According to the segmented regression model,the tumor recurrence rate for en bloc spondylectomy showed a significant downward trend over time,with relatively higher recurrence rates before 2009 and a relatively stable trend after 2014.The results of univariate analysis showed that surgical margin and time of admission were the influencing factors of patient recurrence.The results of multivariate analysis showed that the R1 resection(OR=13.453,95%CI:2.897 to 97.941,P=0.002)and R2 resection(OR=11.379,95%CI:2.658 to 79.429,P=0.003)were independent influencing factor affecting patient recurrence.Conclusions The overall tumor recurrence rate after en bloc spondylectomy was high.The surgical margin of tumor resection is an independent risk factor affecting tumor recurrence.Specifically,R2 and R1 resections significantly increase the risk of tumor recurrence.