手术治疗脊髓Ⅱ级室管膜瘤预后影响因素的系统分析

Systom review on prognostic factors of surgical treatment for grade Ⅱ spinal ependymoma patients

中文关键词:  脊髓室管膜瘤  手术治疗  影响因素  无进展生存情况  总体生存情况  生存分析

英文关键词:Spinal ependymoma  Surgery  Influencing factors  Progression free survival  Overall survival  Survival analysis

中文摘要:

  【摘要】 目的：明确经手术治疗的脊髓Ⅱ级室管膜瘤患者预后的影响因素，并评估其生存情况。方法：由两位研究员对PubMed、Embase、Ovid、CNKI及万方数据库进行检索，检索范围为建库到2017年11月。检索词包括“脊髓室管膜瘤”或各种脊髓Ⅱ级室管膜瘤组织分型。文章纳入标准：文献对每个病例信息都仔细阐述，准确描述病例的组织分型特点，均采用手术治疗。排除标准：患者原发灶位于脊髓之外，病例信息及组织分型特点不全，非手术治疗。按照年龄将患者分为＜18岁组与≥18岁组进行分析。根据肿瘤切除范围将患者分为完全切除（total resection，TR）组、部分切除（subtotal resection，STR）组及活检和减压（biopsy & decompression）组进行比较。按照病理分型将患者分为细胞型、乳头状型、透明细胞型、伸长细胞型、巨细胞型室管膜瘤及未分型Ⅱ级室管膜瘤（纳入未明确阐述Ⅱ级室管膜瘤组织学分型的患者）共6组进行比较。按照辅助治疗情况将患者分为辅助治疗（adjuvant treatment，AT）组和未采用辅助治疗（no adjuvant treatment，NAT）组进行比较。采用单变量Kaplan-Meier法分析各变量与无进展生存时间（progression free survival，PFS）及总体生存时间（overall survival，OS）的关系，采用多变量Cox回归分析评估风险比（hazard ratio，HR）及95%可信区间（95% credibility interval，95%CI），P＜0.05为差异有统计学意义。结果：共纳入35篇文献，包括154例脊髓Ⅱ级室管膜瘤患者，其中男82例，女72例。平均年龄、症状持续时间、随访时间、肿瘤长度、PFS、OS分别为35.7±17.2岁、22.3±26.7个月、56.6±53.1个月、4.6±3.7个椎体层面、35.0±38.4个月、44.7±53.1个月。单变量Kaplan-Meier法分析结果，无统计学差异（P＞0.05）者包括：＜18岁组与≥18岁组PFS及OS，透明细胞型、伸长细胞型与未分型Ⅱ级室管膜瘤PFS及OS，巨细胞型与未分型Ⅱ级室管膜瘤PFS，细胞型、乳头状型与未分型Ⅱ级室管膜瘤OS，TR组、STR组与活检及减压组PFS及OS，AT组与NAT组OS；有统计学差异者包括：细胞型（P＜0.001）、乳头状型（P=0.007）及接受辅助治疗患者的PFS较其他患者短（P＜0.001），巨细胞型室管膜瘤患者比其他患者OS短（P=0.001），AT组比NAT组PFS明显延长（P＜0.001）。Cox回归分析结果，无统计学差异（P＞0.05）者包括：细胞型、乳头状型、透明细胞型、伸长细胞型、未分型Ⅱ级室管膜瘤的OS，TR组、STR组的PFS及OS，AT组与NAT组的OS；有统计学差异者包括：细胞型室管膜瘤（HR=7.784，95%CI 3.307~18.318，P＜0.001）、乳头状室管膜瘤（HR=10.536，95%CI 2.116~52.461，P=0.004）及接受辅助治疗（HR=0.224，95%CI 0.107~0.468，P＜0.001）的肿瘤进展风险较高；巨细胞型室管膜瘤（HR=31.673，95%CI 2.771~361.978，P=0.005）死亡风险较高；AT组比NAT组PFS更长（HR=0.224，95%CI 0.107~0.468，P＜0.001）。结论：脊髓Ⅱ级室管膜瘤患者的病理分型为影响其手术疗效的重要因素。细胞型、乳头状室管膜瘤及采用辅助治疗的患者PFS相对较短，复发风险较高；巨细胞型室管膜瘤OS相对较短，死亡风险较高。手术切除范围不会明显影响治疗效果，辅助治疗并不能有效改善患者生存情况。

英文摘要:

  【Abstract】 Objectives: To identify the prognostic factors of patients with grade Ⅱ spinal ependymoma, and to estimate the survival outcomes. Methods: PubMed, Embase, Ovid, CNKI and Wanfang databases were searched by two investigators. The search was conducted in the time period from database construction to November 2017. The search terms were "spinal cord ependymoma" or other histological classifications of Grade Ⅱ ependymomas. Inclusion criteria were: single case information was presented, and diagnosis was confirmed by pathological examination; all the patients were treated by surgery. Exclusion criteria were: primary lesion was extramedullary; studies did not focus on histological classifications or data were not available; the follow-up data were not referenced; nonsurgical treatment. Data of patient characteristics such as age, sex, complaints, location and length of tumor, extent of resection, strategy of adjuvant treatment, recurrence or progression of disease, mortality, time to recurrence or death, and follow-up time were collected. The ages of the patients were categorized into two groups: age ＜18 and age ≥18. The extents of resection were divided into three groups: total resection(TR), subtotal resection(STR) and biopsy & decompression. The pathological classifications were divided into six groups: cellular ependymoma, papillary ependymoma, clear cell ependymoma, tanycytic ependymoma, giant cell ependymoma, typical Grade Ⅱ ependymoma(the patients whose histological classifications of Grade Ⅱ ependymoma were not stated). The adjuvant treatments were divided into two groups: adjuvant treatment(AT) and no adjuvant treatment(NAT). Univariate Kaplan-Meier analysis was carried out to identify variables associated with progression free survival(PFS) and overall survival(OS). Multivariate Cox regression was performed to estimate hazard ratios(HR) with 95% confidence intervals(95%CI). Statistical analysis was performed by SPSS version 17.0. Statistical significance was defined as P<0.05. Results: A total of 35 studies was identified, including 154 cases of Grade Ⅱ spinal ependymoma consisted of 82 males and 72 females. The mean of age, duration of symptoms, follow-up time, tumor length, recurrence time, PFS, OS was 35.7±17.2 years, 22.3±26.7 months, 56.6±53.1 months, 4.6±3.7 vertebra levels, 35.0±38.4 months, 44.7±53.1 months, respectively. Univariate Kaplan-Meier analysis showed no significant difference(P>0.05) including: PFS and OS between <18 years group and >18 years group; PFS and OS between clear cell ependymoma or tanycytic ependymoma and classic Grade Ⅱ ependymoma; PFS between giant cell ependymoma and classic Grade Ⅱ ependymoma; OS between cellular ependymoma or papillary ependymoma and classic Grade Ⅱ ependymoma; PFS and OS between TR group or STR group and decompression & biopsy group; OS between AT group and NAT group. Those with statistical differences included: patients with cellular ependymoma, papillary ependymoma or adjuvant therapy would have shorter PFS than others(P<0.001, P=0.007, P<0.001, respectively); patients with giant cell ependymoma would have shorter overall survival than others(P=0.001); PFS in AT group was better than NAT group(P<0.001). Cox regression analysis showed no significant difference(P>0.05) including: OS in cellular ependymoma, papillary ependymoma, clear cell ependymoma, tanycytic ependymoma and classic Grade Ⅱ ependymoma; OS between TR group and STR group; OS between AT group and NAT group. Those with statistical differences included: cellular ependymoma(HR=7.784, 95%CI 3.307-18.318, P<0.001), papillary ependymoma(HR=10.536, 95%CI 2.116-52.461, P=0.004) and AT group(HR=0.224, 95%CI 0.107-0.468, P<0.001) had higher progression risk than others; giant cell ependymoma had a higher mortality risk than others(HR=31.673, 95%CI 2.771-361.978, P=0.005); there was better PFS in AT group compared to NAT group(HR=0.224, 95%CI 0.107-0.468, P<0.001). Conclusions: The pathological subtype of Grade Ⅱ spinal ependymoma is important factor influencing surgical outcomes. Cellular ependymoma, papillary ependymoma, adjuvant therapy are associated with shorter PFS. Giant cell ependymoma has shorter overall survival than others. Resection scope does not significantly affect the therapeutic effect. Adjuvant therapy can not improve outcomes after surgical treatment.