Behandlungsstrategien bei Wirbelsäulenmetastasen

 

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Zusammenfassung

Metastasen an der Wirbelsäule treten in bis zu 10 % aller Krebspatienten im Krankheitsverlauf auf. Eine Metastase der Wirbelsäule muss als eine Manifestation einer systemischen Tumorerkrankung gesehen werden, die Behandlung der Absiedlung an der Wirbelsäule beeinflusst in der Regel nicht den Verlauf der Grunderkrankung. Die Therapieentscheidung wird vom Primärtumor, Vorhandensein neurologischer Ausfälle, der Stabilität der Wirbelsäule, dem Ausmaß der Disseminierung viszeral und ossär und dem Gesamtzustand des Patienten beeinflusst und soll zielgerichtet auf die zu erwartende Prognose in Abstimmung mit dem Patienten erfolgen. Begleitend dazu stehen einige valide prognostische Scores zur Verfügung, die an Therapieempfehlungen gekoppelt sind. Bezüglich des Stellenwerts der chirurgischen Behandlung hat in den letzten Jahren ein Wertewandel stattgefunden, der durch eine Verbesserung der chirurgischen und anästhesiologischen Möglichkeiten unterstützt war. Eine Operation ist bei instabiler Wirbelsäulensituation (immanent oder drohend) und vorhandenen neurologischen Ausfällen bei entsprechendem Allgemeinzustand und Lebenserwartung des Patienten indiziert. Dies kann von ventral, dorsal oder von kombiniert ventrodorsalen Verfahren erzielt werden. Eine alleinige Laminektomie ist heute nicht mehr als „State-of-the-art“-Vorgehen anzusehen. Als alternative und komplementäre Therapien sind Strahlentherapie, stereotaktische Radiochirurgie, medikamentöse Chemotherapie und Hormontherapie und additive Verfahren wie sequenzielle Embolisationen, antiresorptive Medikation und Kortisontherapie zu nennen. Die Festsetzung der Therapie soll interdisziplinär durch ein multidisziplinäres Tumorboard erfolgen. Bei allen Therapieentscheidungen stehen Palliation und Optimierung der Lebensqualität im Vordergrund.

Abstract

Spinal metastases occur in 10 % of all carcinoma patients in the course of their oncologic disease. Spinal metastasis is a manifestation of a systemic oncologic disease. The treatment of the metastasis does not influence the overall oncological outcome. Treatment decision is depending from the primary tumor, presence of neurological symptoms, stability of the spine, extent of visceral and osseous dissemination, general state of the patient and his life expectancy. Therapy should focus on the patientʼs needs and be correlated with the expectations and prognosis of the patient. There exist a number of valid prognostic scores to support and objectify the decision. There has been a change of paradigmata with regard to surgical treatment, supported by an improvement in oncosurgical and anesthesiological fields. Surgery is indicated in case of instability or neurological compromise, in respect of the general state and life expectancy and can be performed from a ventral, dorsal or combined approach. Alternative or complimentary treatment methods are radiotherapy, chemotherapy, hormonotherapy, stereotactic radiosurgery and additive therapies like sequential embolization, antiresorptive medication or corticoid therapy. Therapy should be established by a multidisciplinary tumor board. Main issue for treatment decisions is palliation and optimizing the patientʼs quality of life.

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