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Kyphoplastie kombiniert mit intraoperativer Radiotherapie (Kypho-IORT)

Therapiealternative für den oligometastasierten Patienten mit Wirbelsäulenmetastasen

Kyphoplasty combined with intraoperative radiotherapy (Kypho-IORT)

Alternative therapy for patients with oligometastatic spinal metastases

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Zusammenfassung

Hintergrund

Durch verbesserte onkologische Therapie kommt es nicht nur zu einer deutlich verbesserten Überlebenszeit, sondern auch zu einer Zunahme an ossären Metastasen bei Tumorpatienten. Die häufigste Lokalisation stellt dabei die Wirbelsäule dar, die Folge können Instabilität, Schmerz und neurologische Defizite sein. Das interdisziplinäre Tumormanagement der Wirbelsäule umfasste bisher insbesondere die Stabilisierung und anschließende Bestrahlung der Metastasen. Eine Reduktion der Eingriffsschwere und Morbidität sind ebenso wie die Beachtung und Erhalt der Autarkie des Patienten wichtige Zielparameter bei diesen palliativen Patienten.

Methode und Resultate

Die Kyphoplastie kombiniert mit intraoperativer Radiotherapie (Kypho-IORT) stellt eine weitere, moderne Behandlungsoption für Patienten dar, bei welcher minimal-invasiv eine lokale Hochdosisbestrahlung im Wirbelkörper mittels niedrigenergetischen Röntgenstrahlen (50 kV) transpedikulär vorgenommen wird. Unmittelbar anschließend erfolgt die Stabilisierung des Wirbelkörpers über das gleiche Portal mittels Kyphoplastie, sodass eine einzeitige Prozedur mit guter Schmerzreduktion und guter lokaler Tumorkontrolle erzielt werden kann. Neben der Präsentation klinischer Daten werden die Indikationsstellungen zur Kypho-IORT in diesem Artikel kritisch dargestellt und mit anderen Therapieoptionen verglichen. Methodische Verbesserungen und Möglichkeiten zur weiteren Individualisierung der Therapie werden aufgezeigt.

Schlussfolgerung

Die Kypho-IORT ist eine neue Behandlungsoption für Patienten mit Wirbelsäulenmetastasen. Nach über 100 erfolgreichen Anwendungen sind technische Machbarkeit, Patientensicherheit und gute lokale Tumorkontrolle dargelegt, sodass eine Anwendung im klinischen Alltag möglich und sinnvoll erscheint. Eine Phase-II-Dosiseskalationsstudie ist abgeschlossen und zur Publikation eingereicht, eine Phase-III-Studie zum Vergleich mit konventioneller Bestrahlung ist begonnen worden.

Abstract

Background

Due to a more effective systemic therapy the survival of patients suffering from malignant tumors has been significantly improved but a longer life span is often associated with a higher incidence of osseous metastases. The majority of these metastases are localized in the spine causing pain, instability and neurological impairments. The interdisciplinary management of spinal metastases previously consisted of stabilization followed by fractionated external body radiation therapy. A reduction in procedural severity and morbidity as well as consideration of self-sufficiency and hospitalization time are important target parameters for these palliative patients.

Method and results

Kyphoplasty combined with intraoperative radiotherapy (Kypho-IORT) is one of several modern treatment options, which involves a minimally invasive procedure with local high-dose transpedicular irradiation of the spine with low-energy (50 kV) X-rays. Immediately following irradiation, stabilization of the spine is carried out using kyphoplasty via the same access route so that a single stage procedure with excellent pain reduction and good local tumor control can be achieved. This article presents clinical data for this procedure and the different fields of indications are critically reviewed and compared to other therapy options. Methodological improvements and options for further individualization of therapy are demonstrated.

Conclusion

The Kypho-IORT procedure is a safe, feasible and beneficial modern treatment option for instant stabilization and local tumor control in patients with spinal metastases. More than 100 operations have been successfully performed so that the method can be deemed suitable for inclusion in the clinical routine. A phase II dose escalation study has now been completed and submitted for publication and a 2-arm non-inferiority trial (phase III study) for comparison with conventional irradiation is in progress.

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Authors and Affiliations

  1. Orthopädisch-Unfallchirurgisches Zentrum, Universitätsklinikum Mannheim, Med. Fakultät Mannheim der Universität Heidelberg, Theodor-Kutzer-Ufer 1, 68167, Mannheim, Deutschland

    F. Bludau & U. Obertacke

  2. Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Mannheim, Med. Fakultät Mannheim der Universität Heidelberg, Theodor-Kutzer-Ufer 1, 68167, Mannheim, Deutschland

    T. Reis, F. Schneider, S. Clausen & F. Wenz

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  1. F. Bludau
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  2. T. Reis
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  4. S. Clausen
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Correspondence to F. Bludau.

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Interessenkonflikt

F. Bludau, T. Reis, F. Schneider, S. Clausen, F. Wenz und U. Obertacke weisen auf folgende Beziehungen hin: Alle Autoren wurden von der Firma Carl Zeiss bei der Entwicklung der Instrumente (Hülsensysteme) und von den Firmen Zeiss und Medtronic bei der Durchführung des Lehrformats (Kadavertraining) unterstützt. Darüber hinaus erhielt der Erstautor Reisekostenunterstützung zu Kongressen. Alle angewandten Verfahren stehen im Einklang mit den ethischen Normen der verantwortlichen Kommission für Forschung am Menschen (institutionell und national) und mit der Deklaration von Helsinki von 1975 in der revidierten Fassung von 2008.

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Die Autoren F. Bludau und T. Reis haben zu gleichen Teilen zu der Arbeit beigetragen.

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Bludau, F., Reis, T., Schneider, F. et al. Kyphoplastie kombiniert mit intraoperativer Radiotherapie (Kypho-IORT). Radiologe 55, 859–867 (2015). https://doi.org/10.1007/s00117-015-0018-1

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