医学病例讨论： Metastatic spine disease.pptxVIP

metastatic spine disease: Evolution XU WENBIN SIR RUN RUN SHAW HOSPITAL backgroundIn the USA, nearly 300 000 adults have osseous metastatic disease, with approximately 60% of the metastases being spinal metastases. Approximately 10% of patients with spinal metastases develop spinal cord compression—a severe and often permanently disabling condition that is an oncological emergency. Historically, spinal metastases have been treated with invasive surgical approaches (eg, en-bloc resection), or low-dose palliative conventional external-beam radiotherapy (EBRT), or both. backgroundEvolution of surgery can be traced from inappropriate open surgery (i.e. laminectomy) to appropriate open (i.e. posterior instrumentation and decompression) and further to minimally invasive surgery. Presently, the best clinical outcomes are achieved by surgery with timely postoperative radiotherapy. spine stereotactic body radiotherapy (SBRT) ,spine stereotactic radiosurgery (SRS) Primary site乳腺22%肺15%前列腺10%黑色素瘤9%淋巴瘤7%胃肠道5%肾脏6%甲状腺3%男性：肺癌，前列腺癌，肾癌，肝癌，胃癌。女性：乳腺癌、肺癌、子宫癌、甲状腺癌、结肠癌、胃癌。Life expectancy肺癌：术后4月结肠癌：7月肾癌：11.3月前列腺癌：14月乳腺癌：21月肝癌：2年甲状腺癌：10年（80-95%）1年：48%5年：1.5%Involved segmentAutopsy studies have demonstrated the lumbar spine to be most commonly involved, followed by the thoracic and cervical segments.Clinically, symptomatic spinal metastases are most often localized to the thoracic spine (with special predilection for the segments about T4 and T11), followed by the lumbar and cervical segments.Thoracic 70%Lumbar 20%Cervical 10%metastasis pathwayHematogenous metastasis：Batson’s venous plexus，cancer embolusLymphatic metastasisImplantation metastasisCSF metastasisClinical manifestationRadiological examX 线平片是脊柱转移瘤诊断最基本的影像学检查方法，常表现为骨质疏松、溶骨性或硬化性改变，以椎弓根消失（猫头鹰眨眼征）、椎体塌陷较常见，椎间隙通常正常。博兰（Boland）等认为椎体的扁平压缩比楔形变更有意义。 相比 X 线平片，核素全身骨扫描可提前 3~6 个月发现骨性损害，其灵敏度高达 95%~97%, 多表现为放射性浓聚，对可疑骨转移瘤患者应尽量作骨扫描检查。 对于椎体破坏及椎旁、椎管内占位性病变，应用 CT 检查显示较清楚，但当病变较小、CT 扫描层距较宽时，容易漏诊。 对于软组织病变检查，MRI 可提供比 X 线平片、同位素、CT 等检查更精确的影像学信息。对于选择治疗方法、手术