| [Purpose] This study aims to create and validate a new scoring system that can guild surgeons to select the optimal therapy for patients with metastatic spinal cord compression(MSCC).[Content] Predicting survival and functional outcome is essential when selecting the individual treatment for patients with MSCC.Generally speaking,patients with a life expectancy of 3 to 6 months can be treated with surgery,while patients with a life expectancy of less than 3 months are best treated with radiotherapy or best supportive care alone.Life expectancy can be assessed with the help of scoring systems,including Tokuhashi scoring system,Tomita scoring system,Bauer scoring system,Linden scoring system,Sioutos scoring system,Rades scoring system,and Katagiri scoring system et al.Perhaps the Tomita score(2001)and the revised Tokuhashi scores(2005)were the most representative and commonly used scores among them.Those scoring system can help clinical doctors to treat spine metastasis,which can help to avoid excessive treatments and insufficient medicine.Unfortunately,the most of available scoring systems were designed in the 1990 s and early 2000 s,those scoring system did not take the effectiveness of new therapeutic strategies on survival into consideration,contributing to a progressive loss of accuracy,which has been reported in many studies.Thus,a retrospective series of patients was used to create a new scoring system,and a prospective series of patients was used to validate the scoring system in the present study.[Methods] We retrospectively analyzed 12 preoperative characteristics for postoperative survival in a series of 206 patients with MSCC who were operated with decompressive surgery and spine stabilization from May 2005 and September 2015.The 12 preoperative characteristics include age,gender,primary site,preoperative ambulatory status,Eastern Cooperative Oncology Group(ECOG)performance status,number of involved vertebrae,visceral metastases,preoperative chemotherapy,bone metastasis at cancer diagnosis,the time developing motor deficits,preoperative albumin,and radical surgery at primary site.Simple and multiple Cox proportional hazards regression models were used to analyze those preoperative factors.Characteristics significantly associated with survival in the multivariate Cox analysis were included in the scoring system.The scoring point for each significant factor was derived from the hazard ratios on multiple Cox proportional hazards regression model.The total prognostic score for each patient was determined by adding the scoring points of every significant factor.Taking into account the median survival time and 6 months survival rate of each score,groups were designed.Postoperative function outcome was also analyzed on the basis of the groups of the scoring system.Then,we prospectively analyzed 86 patients with MSCC(89 patients were recruited)from three hospitals(the three levels)between June 2015 and September 2016.Those patients were divided into the same prognostic groups according to the scoring system.Kaplan-Meier method and log-rank test were used to compare the survival prognosis among the groups.Chisquare test was used to compare the ambulatory rates between the groups.ROC curves were performed to estimate and compare the accuracy and c-statistic of the scoring model and the Tomita scoring model.This study was registered at Chinese Clinical Trial Registry(ChiCTR-POC-16008393).[Results] According to the multivariate analysis,primary site(P<0.01),preoperative ambulatory status(P<0.01),visceral metastases(P<0.01),preoperative chemotherapy(P=0.02),and bone metastasis at cancer diagnosis(P=0.03)had a significant impact on postoperative survival and were included in the scoring system.The scoring point for each significant factor was derived from the hazard ratios on multiple Cox proportional hazards regression model.Patients with slow growth cancer is given 2 points,patients with moderate growth cancer is given 1 point,and patients with rapid growth cancer is given 0 point.Ambulation before surgery is given 2 points and non-ambulation before surgery is given 0 point.Patients without visceral metastases is given 3 points and patients with visceral metastases is given 0 point.Patients with preoperative chemotherapy is given 2 points and Patients without preoperative chemotherapy is given 0 point.Bone metastasis at cancer diagnosis is given 0 point and no bone metastasis at cancer diagnosis is given 1 point.The higher scores were linked to better outcome.According to the prognostic scores,which ranged from 0 to 10 points,three risk groups were designed: 0 to 2(Group A),3 to 5(Group B),and 6 to 10 points(Group C).The corresponding median overall survival time was 3.3 months,6.6 months,and 16.4 months,respectively(P<0.01),the corresponding 6 months survival rates were 8.2%,56.5%,and 91.5%,and the corresponding postoperative ambulatory rates were 35.7%,73.3%,and 95.9%,respectively(P<0.01).In the prospective validation group,the corresponding median overall survival time was 3.9 months,6.7 months,and 12 months,respectively(P<0.01),the corresponding 6 months survival rates were 27.8%,66.0,and 88.0%,and the postoperative ambulatory rates were 55.6%,73.5%,and 94.1%,respectively(P?0.01).The ROC curve c-statistics for the scores as a predictor of 3,6,and 12 months survival rates were 0.75,0.74,and 0.70,respectively,and the corresponding accuracy rates were 69.1%,69.2%,and 64.9%.The corresponding ROC curve c-statistics for the Tomita scores were 0.70,0.68,and 0.66,respectively,and the corresponding accuracy rates were 58.4%,58.4%,? 56.4 %.[Conclusion] This scoring system can help select the optimal therapy for patients with MSCC and can be considered valid and reproducible to estimate the survival prognosis and functional outcome,and that scoring system is a useful scoring system.Patients with scores of 0 to 2 points,who have the shortest survival time and poorest function outcome,appear best treated with radiotherapy or best supportive care alone,while patients with scores of 3 to 5 points should be the best surgical candidates,because survival prognosis and function outcome are preferable after surgery,and patients with scores of 6 to 10 points,who have the most favorable survival prognosis and function outcome,can be treated with more radical surgery to realize better local control of disease and prevent the occurrence of local disease.Moreover,its capability to predict survival prognosis was relatively better than the Tomita scoring system according to ROC curves and accuracy rates,which indicate that the present scoring system can be widely used in clinical routine. |
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