脊柱非何杰金淋巴瘤的治疗方法选择及评价

Treatment strategy and evaluation of spinal non-Hodgkin′s lymphomas

中文关键词:  脊柱非何杰金淋巴瘤  治疗  手术  化疗  放疗

英文关键词:Non-Hodgkin′s lymphomas of the spine  Treatment  Surgery  Chemotherapy  Radiotherapy

中文摘要:

  【摘要】 目的：探讨脊柱非何杰金淋巴瘤的治疗方法选择及疗效。方法： 2006年6月~2012年11月我院骨科收治并获随访的脊柱非何杰金淋巴瘤患者15例，男8例，女7例，年龄42±18岁（16~71岁）。局部疼痛14例。神经功能损害11例，其中脊髓损害5例，Frankel C级3例，D级2例；马尾损害6例。11例患者行CT引导下穿刺活检，8例确诊为淋巴瘤，1例误诊为Langerhans细胞增多症，2例仅诊断为“小细胞恶性肿瘤”，其余患者经术后病理检查确诊。15例患者中，5例未接受手术治疗，其中4例不伴严重神经损害及节段不稳定患者，经穿刺活检确诊后，首选化疗，均未接受进一步放疗；1例患者为马尾综合征，无法耐受手术，行急诊放疗，后行化疗。10例接受手术治疗，其中7例患者因神经功能损害合并节段不稳定行手术治疗，术后1例患者未接受进一步治疗，4例患者接受化疗及放疗，2例患者接受单纯化疗；1例患者行穿刺活检未能确诊，因节段不稳定行手术，病理检查确诊后接受化疗；2例患者伴病理性骨折，行经皮穿刺椎体成形术（percutaneous vertebroplasty，PVP），术后1例行化疗，1例行化疗+放疗。手术患者术前Karnofsky日常状态评分（Karnofsky performance score，KPS）为47±18分，疼痛视觉模拟评分（visual analog score，VAS）评分为7.7±1.0分；非手术患者治疗前KPS为62±18分，VAS评分6.4±1.0分。结果：15例随访时间为52±34个月（3~108个月），其中5例死亡（分别存活3、10、10、15、25个月）。局部疼痛患者经治疗后症状均有缓解，其中3例完全缓解。11例神经损害者，3例保守治疗，8例手术，手术患者中脊髓损伤4例，末次随访Frankel分级至少改善1级，其中2例完全恢复，所有马尾损伤患者均明显恢复。手术患者末次随访时VAS评分为1.4±1.0分，较术前明显降低（P＜0.05）；末次随访时KPS评分为91±15分，较术前有显著提高（P＜0.05）。非手术治疗患者5例，4例存活，末次随访时VAS为1.0±0.6分，KPS为76±10分，与治疗前比较均有统计学差异（P＜0.05）。所有患者预期5年生存率为66.7%，其中手术患者为60%，非手术患者为80%。结论：对于脊柱非何杰金淋巴瘤，化疗及放疗为最主要的治疗手段；对于神经损伤重、结构不稳定的患者，手术治疗可有效解除脊髓压迫、改善神经功能及稳定结构，提高生活质量。

英文摘要:

  【Abstract】 Objectives: To discuss the choice, effectiveness and outcome of different treatment in patients with non-Hodgkin′s lymphomas of the spine. Methods: Between June 2006 and November 2012, 15 patients with spinal non-Hodgkin′s lymphomas undergoing treated in our department were reviewed retrospectively. There were 8 males and 7 females, with an average age of 42±18 years(range: 16 to 71 years old). 14 patients presented with local pain and 11 with neurologic deficits, 5 patients suffered from spinal cord compression(Frankel grade C in 3 patients, D in 2), 6 cases had caunda equina syndrome. CT guided percutaneous biopsy was performed on 11 patients, 8 of whom were lymphoma, 1 was misdiagnosed to Langerhans cell histiocytosis, 2 were diagnosed as small cell malignant tumor. The other 7 cases were histologically diagnosed as lymphoma postoperatively. Among all the 15 patients, 5 did not receive surgery, after diagnosis, 4 patients without severe neural dysfunction or segmental instability received chemotherapy alone, 1 patient with Cauda Equina syndrome who could not tolerate surgery received emergent radiotherapy followed by chemotherapy. Surgery was performed on 10 patients, 7 patients received open surgery due to neural compression with segmental unstableness, 1 patient did not receive further treatment, 4 patients undergone chemotherapy and radiotherapy, 2 patients received chemotherapy. 1 patient who failed in percutaneous biopsy and with segmental instability, received surgery followed by chemotherapy. 2 patients with pathological fracture received percutaneous vertebroplasty(PVP) and further chemotherapy and/or radiotherapy. At preoperation, the average Karnofsky performance score(KPS) was 47±18, and the average visual analog score(VAS) was 7.7±1.0. In non-surgical group, the average KPS was 62±18, the average VAS was 6.4±1.0 before treatment. Results: 15 patients were followed up for an average of 52±34 months(range: 3 to 108 months). 5 patients died(survival time: 3, 10, 10, 15, 25 months). All patient who suffered from local pain got complete pain relief in 3 cases. In the 11 patients with neurologic deficit, 3 were treated conservatively, the other 8 had surgical treatment. In surgical group, 4 patients with myelopathy had at least one Frankel grade improvement, including 2 complete recovery. All patients with cauda equina syndrome were significantly recovered after surgery. The average KPS was 91±15 in the latest follow-up, and the average VAS was 1.4±1.0(P<0.05). In the 5 non-surgical patients, 4 were alive, in the latest follow-up the average VAS was 1.0±0.6, the average KPS was 76±10 significantly improved after treatment(P<0.05). The estimated 5-year survival rate was 66.7%, while the estimated 5-year survival rate of surgical group was 60%, verses 80% in non-surgical group. Conclusions: For non-Hodgkin′s lymphoma of spine, chemotherapy and radiotherapy are the primary treatments. For patients with severe neurological deficit or obvious segmental unstableness, surgical treatment could be helpful to achieve pain relief, stabilization and neurological recovery, therefore improve life quality.