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Solitäre Metastasen der Wirbelsäule

Indikationen für eine aggressive chirurgische Therapie?

Solitary spinal metastases

Is aggressive surgical management justified?

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Zusammenfassung

Fortschritte der onkologischen und chirurgischen Therapien haben zu einer deutlich steigenden Lebenserwartung von Patienten mit malignen Erkrankungen mit verlängertem Überleben bei bestehender Metastasierung geführt. Das Skelettsystem, mit Präferenz der Wirbelsäule, ist als Fernmetastasierungsort dabei mit am häufigsten betroffen. Durch Nutzung neuartiger bildgebender Verfahren mit höherer Auflösung und Verwendung metabolischer Signaturen hat sich das Screening von Tumorpatienten deutlich verbessert, sodass die Diagnose einer Metastasierung zunehmend eher und sensitiver gestellt wird. Daher, aber auch aufgrund der effektiveren Polychemotherapieprotokolle werden singuläre/solitäre Metastasen immer häufiger entweder im Anfangsstadium oder aber als Zeichen einer kontrollierten malignen Tumorerkrankung („stable disease“) beobachtet. Inwieweit eine „solitäre Metastase“ wirklich existiert („Illusion oder Realität?“) und deren radikale onkologische und chirurgische Behandlung als umschriebene singuläre Tumormanifestation überhaupt prognoserelevant ist, bleibt weiterhin stark umstritten. Evident ist jedoch, dass eine prognostisch günstige zugrundeliegende Tumorbiologie, die radikale Behandlung des Primärtumors und ein langes metastasenfreies Intervall valide Prädiktoren für eine gute onkologische Prognose sind. Bei Vorliegen einer solitären Metastase unter diesen Umständen (klassisches Beispiel: solitäre Nierenzellkarzinommetastase etliche Jahre nach radikaler Tumornephrektomie) kann dann ein radikal chirurgisches Vorgehen (En-bloc-Spondylektomie) in Verbindung mit adjuvanter Chemo- und/oder Radiotherapie die Langzeitprognose dieser Patientengruppe signifikant verbessern. Hierbei sind die gründliche Evaluation der Überlebensprognose, ein lückenloses Staging und die interdisziplinäre Therapieentscheidung im Tumorboard von entscheidender Bedeutung.

Abstract

Advances in oncological and surgical therapies have led to a significant increase in life expectancy of cancer patients and also prolonged survival of patients with isolated or multiple metastases. Among the skeletal manifestations the spine is the most often affected site. Using novel imaging techniques with higher resolution and use of metabolic signatures, the screening of cancer patients has improved considerably. Consequently, the diagnosis of metastases is becoming increasingly more sensitive. Therefore, but also due to more effective polychemotherapy protocols, singular or solitary metastases are more frequently observed either in the early stages or as a result of a controlled malignant tumor entity (stable disease). The questions whether a solitary metastasis really exists (illusion or reality?) and its radical oncological and surgical treatment as a circumscribed singular tumor manifestation, is really relevant for the overall prognosis, remains controversial. However, it seems evident that a biologically favorable underlying tumor biology, radical treatment of the primary tumor and a long metastasis-free interval are valid predictors of a good oncological outcome. In the presence of a solitary metastasis under these circumstances (typical example: solitary metastasis of renal cell carcinoma many years after radical tumor nephrectomy) a radical surgical procedure (en bloc spondylectomy) can significantly improve the long-term prognosis of this patient group in combination with adjuvant chemotherapy and/or radiotherapy. However, a thorough evaluation of the overall survival prognosis, a detailed and complete staging followed by a treatment consensus in the interdisciplinary tumor board has to precede any therapeutical decisions.

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Interessenkonflikt. C. Druschel, A.C. Disch, M. Pumberger, P. Schwabe, I. Melcher, N.P. Haas, K.-D. Schaser geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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  1. Centrum für Muskuloskeletale Chirurgie, Klinik für Orthopädie, Klinik für Unfall- und Wiederherstellungschirurgie, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland

    C. Druschel, A.C. Disch, M. Pumberger, P. Schwabe, I. Melcher, N.P. Haas &  K.-D. Schaser

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  1. C. Druschel
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Druschel, C., Disch, A., Pumberger, M. et al. Solitäre Metastasen der Wirbelsäule. Orthopäde 42, 709–724 (2013). https://doi.org/10.1007/s00132-013-2066-4

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