Treatment of neoplastic epidural cord compression by vertebral body resection and stabilization

The results of treatment of neoplastic spinal cord compression by vertebral body resection and immediate stabilization in 101 consecutive patients over a 5-year period have been analyzed. Sites of primary cancer included the lung (25 patients), kidney (15 patients), breast (14 patients), connective tissue (12 patients), and a variety of others (35 patients). Of the 101 patients, 23 received surgery de novo; the remaining 78 patients had undergone previous therapy. Sites of involvement included the cervical region in 13 patients, the thoracic region in 68 patients, and the lumbar region in 20 patients. Prior to surgery, severe pain was noted in 90% of the patients, and 45% were non-ambulatory. Using an anterolateral surgical exposure, the vertebral body was resected along with all epidural tumor. Immediate stabilization was achieved with methyl methacrylate and Steinmann pins. Following surgery, the overall ambulation rate was 78%, and 85% of patients experienced pain relief. Of the 23 patients who had received no prior therapy, 90% continued to be ambulatory at their last follow-up examination or until death. The authors believe that surgery prior to irradiation is indicated in selected patients with neoplastic cord compression. In patients with solitary osseous metastasis to the spine, potentially curative resection can be undertaken if surgery is performed when the tumor is still confined to the vertebral body.

Spinal chordomas

A series of 54 patients with spinal chordomas were treated at Memorial Sloan-Kettering Cancer Center between 1949 and 1976. Thirty-six lesions were located in the sacrococcygeal region and 18 involved the vertebral column at a higher level. The male to female ratio was 35:19. Vertebral chordomas generally occurred in a younger age group. Our radiological findings suggest that there is marked soft-tissue extension anterior to the vertebral column at the time of initial diagnosis. Eleven of 18 vertebral chordomas and 10 of 36 sacral chordomas were found to have disseminated metastases during their course. Analysis of the various modes of therapy reveals that the median survival for both groups is approximately 6 years. However, the 5-year survival for the sacrococcygeal group was 66% as opposed to 50% for the vertebral group. Radiation therapy produced significant palliation but objective evidence of tumor regression was difficult to assess. Chemotherapy in a small number of patients did not have any effect on the tumor. With the advent of computerized tomography scanning, further studies should be done to document the response of this tumor to radiation therapy.

Surgical treatment of brain metastases. Clinical and computerized tomography evaluation of the results of treatment

The results of treatment of brain metastases in a series of 125 patients who underwent surgery with or without postoperative radiation from 1978 through 1982 were analyzed. The major sites of primary tumor included the lung (40%), melanoma-skin (11%), kidney (11%), colon (8%), soft tissue sarcoma (8%), breast (6%), and a variety of others (15%). At the time of craniotomy, disease was considered limited to the central nervous system in 63 patients (50%). After surgery, 83 patients (66%) were neurologically improved, and 26 (21%) had their deficits stabilized. The overall median survival was 12 months, and 25% lived 2 years. Eight patients (12%) are alive 5 years or more following surgery. Survival varied with site of primary tumor, location of brain metastasis, extent of systemic disease, and neurologic deficit at time of craniotomy. Over a follow-up period ranging from 18 months to 6 years, 42 patients (34%) developed either local recurrences or other sites of brain metastases. These data suggest that although craniotomy followed by radiation is highly effective in the initial treatment of selected patients with brain metastases, alternate therapies require investigation in view of the high central nervous system relapse rate in long-term survivors.

Indications and results of combined anterior-posterior approaches for spine tumor surgery

Spinal instrumentation currently allows gross-total resection and reconstruction in cases of malignancies at all levels of the spine. The authors analyzed the results in 110 patients who underwent surgery for primary and metastatic spinal tumors over a 5-year period (1989-1993) at a single institution. Major primary sites of tumor included breast (14 cases), chordoma (14 cases), lung (12 cases), kidney (11 cases), sarcoma (13 cases), plasmacytoma (10 cases), and others (36 cases). Prior to surgery, 55 patients (50%) had received prior treatment. Forty-eight patients (44%) were nonambulatory, and severe paraparesis was present in 20 patients. Fifty-three patients (48%) underwent combined anterior-posterior resection and instrumentation. 33 (30%) underwent anterior resection with instrumentation, 18 (16%) underwent anterior or posterior resection alone, and the remaining six patients (5%) underwent posterior resection and instrumentation. Major indications for anterior-posterior resection included three-column involvement, high-grade instability, involvement of contiguous vertebral bodies, and solitary metastases. Postoperatively, 90 patients improved neurologically. The overall median survival was 16 months, with 46% of patients surviving 2 years. Fifty-three patients (48%) suffered postoperative complications. Despite the high incidence of complications, the majority of patients reported improvement in their quality of life at follow-up review. Our findings suggest that half of all patients with spinal malignancies require combined anterior-posterior surgery for adequate tumor removal and stabilization.

Radiation therapy for spinal epidural metastases with complete block

Myelography was performed in 535 patients at the Memorial Sloan-Kettering Hospital from January 1979 to December 1979. In 110 cases a complete block was demonstrated and of these, 78 had epidural metastases. A uniform treatment was applied using radiation therapy and high dose steroid. The neurologic outcome for each patient was evaluated, correlating pre-treatment neurologic status, pathologic type, nature of block (level, structural versus tumoral), and result of repeat fluoromyelography. Only 2 patients improved, but 11 became completely paraplegic. The survival was influenced by the ambulatory status after treatment (median survival: 52.7 weeks in the ambulatory group and 4.6 weeks in the paraplegic). Based on this series, rational approach and management of complete block secondary to spinal epidural metastases are discussed.

An anterior surgical approach to the upper thoracic vertebrae

Of the various anterior surgical approaches to the spine, exposure of the upper two thoracic vertebrae remains the most challenging. An operative approach to this region is described. The major features include resection of a portion of the clavicle and the manubrium sterni. Following resection of the tumor and involved vertebra, anterior fusion is performed using the clavicle as a strut graft. Immediate stabilization may also be achieved with methyl methacrylate replacement of the vertebral bodies. The operation is well tolerated, and requires minimal postoperative immobilization. The clinical presentation, radiological features, and results of treatment in a series of seven patients operated on during a 2-year period are presented.

Surgical treatment of single brain metastasis: factors associated with survival

The results of surgical excision of solitary intracerebral metastases followed by whole-brain radiation therapy between 1972 and 1978 in a series of 78 patients were analyzed. The overall median survival of the series was 6 months with a 1-year survival rate of 29%. Statistical analyses of the data revealed that patients who presented with a cerebral metastasis 1 year or more after diagnosis of the primary cancer had a significantly longer survival than those in whom the metastasis was detected within 1 year (P less than .04). Patients with mild or no neurological deficits at time of craniotomy had a longer median survival and a 1-year survival of 44% (P less than .01). The presence of metastases at one or two other sites did not significantly affect overall survival except in those patients in whom the brain metastasis was detected more than 1 year after diagnosis of the primary tumor. Factors found to affect survival in this study may be useful in predicting survival of future patients similarly treated.

Treatment of spinal metastases from kidney cancer by presurgical embolization and resection

Surgical treatment of bone metastases from kidney cancer is often complicated by profuse blood loss. The authors report the results of a retrospective review of 30 consecutive patients who underwent surgery for spinal metastases from kidney cancer. Seventeen patients (57%) were operated on after failing radiation therapy. Prior to operation, selective spinal angiography and embolization were performed in 17 patients with no permanent neurological deficits resulting. Gross total resection of the tumor and stabilization of the spine were then accomplished with acceptable blood loss. Twenty-seven (90%) of the 30 patients improved neurologically following surgery. There was a median survival time of 16 months, a 2-year survival rate of 33%, and a 5-year survival rate of 15%. Major surgical complications in this series were related to excessive blood loss in patients without embolization. These data suggest that patients with spinal metastases from kidney cancer should undergo spinal angiography and embolization prior to resection of the tumor. To improve upon current results, such treatment should be carried out prior to external radiation therapy.

Combined treatment of osteosarcoma of the spine

We reviewed the clinical features and results of treatment in 24 patients with osteogenic sarcoma of the spine treated over a 35-year period. There were 14 male and 10 female patients 13 to 71 years old. The tumor arose de novo in 13 patients and was secondary to other conditions in 11. All patients presented with pain, and 16 (67%) had neurological deficits. Patients were divided into two treatment groups. Thirteen patients treated from 1949 to 1977 usually underwent limited tumor resection and external radiation therapy. The second group, 11 patients treated from 1978 to 1984, underwent more aggressive surgical resection and received combination chemotherapy as well as local radiation to the tumor bed. In the second group, there were 5 long term survivors, and only 1 patient developed metastatic disease while on therapy. Failure to obtain local control was the major cause of treatment failure. Complete surgical resection of the tumor by spondylectomy and combination chemotherapy offer the best prospect for cure of osteogenic sarcoma of the spine.

Surgical treatment of spinal cord compression from epidural metastasis

PURPOSE

A retrospective study of the results of neoplastic cord compression was undertaken to determine the effectiveness of surgical treatment and to assess quality of life in patients undergoing extensive procedures with potential morbidity.

PATIENTS AND METHODS

Over a 5-year period (1989 to 1993), a total of 110 patients underwent surgery. Fifty-five patients (50%) had undergone prior treatment, including 47 (43%) who had failed to respond to prior irradiation (RT). Before surgery, 48 patients (44%) were nonambulatory, with severe paresis being present in 20. Surgery included staged anterior-posterior resections in 53 patients (48%), anterior resections in 33 (30%), and posterior resection in six (5%), all of whom required spinal instrumentation for reconstruction; only 18 patients underwent resection without instrumentation.

RESULTS

Postoperatively, 90 patients (82%) were improved, both in terms of pain relief and ambulatory status. Fifty-three patients (48%) experienced postoperative complications, related statistically to the following three factors: age over 65 years, prior treatment, and presence of paraparesis. The overall median survival duration was 16 months, with 46% alive at 2 years. Apart from primary tumor, the presence of preoperative paraparesis had the most significant impact on survival.

CONCLUSION

Our data suggest that the effective surgical treatment of neoplastic compression requires anterior-posterior resection in most patients to achieve the goal of total tumor resection, with the majority requiring instrumentation. Long-term survival is feasible in a subset of patients with this aggressive surgical approach.

Surgical treatment of spinal chordomas

The clinical features and results of 34 patients with chordomas treated over a seven-year period were analyzed. Surgical treatment consisted of wide local excision (n = 6), marginal resection (n = 5), intralesional resection (n = 20), and biopsy (n = 3). Eighteen patients received postoperative radiotherapy. The local recurrence rate was 65%, with 30% of patients developing distant metastases. With the introduction of computed tomography, smaller tumors are currently being diagnosed; as a result, 35% of the patients in this series are disease free, compared with 10% described previously.

Vertebral body resection in the treatment of cancer involving the spine

Results of radical spinal surgery with vertebral body resection in of 51 patients with primary and metastatic cancer of the spine were analyzed. Seven patients had primary spine tumors, 16 had paravertebral tumors that involved the spine by direct extension, and 28 had blood-borne metastases to the spine. Thirty-five patients (68%) had prior therapy directed to the spine: 4 had undergone previous surgery, 9 had surgery and radiation, and 22 had radiation alone. Forty-five patients (90%) had intractable pain, and 25 patients (48%) were nonambulatory. Myelography revealed high-grade or complete block in 39 patients (76%). Following surgery, 38 of 45 (84%) had pain relief, and 40/58 (78%) were ambulatory at discharge. Of the 25 patients who were unable to walk prior to surgery, 15 (60%) improved to fully ambulatory status. The surgical mortality was low (4%), and complications were few (10%). These results are superior to those reported following treatment by radiation and steroid therapy. In selected patients who have actual or potential neural compression resulting from tumor within the vertebral body, such surgery should be considered as initial therapy.

Surgical treatment of spinal cord compression in kidney cancer

Forty-three patients with renal-cell carcinoma underwent treatment for spinal cord compression over a 7-year period. Of these, 32 patients underwent surgery, while 11 patients underwent radiation alone. Before operation, 25 patients had relapsed following prior radiation, while seven others received postoperative radiation. A more aggressive surgical approach, tailored to the site of compression within the spinal canal, was used with the majority undergoing gross total tumor resection by an anterior approach. Immediate stability of the spine was achieved with methyl-methacrylate reconstruction of the resected segments. Preoperative spinal angiography with embolization of hypervascular tumors was carried out in eight patients. Patient parameters in the surgical and irradiated groups were comparable, except that a greater proportion of the radiation alone group had more than one organ system involved (64% v 44%). The median survival of the surgically treated patients was 13 months, compared with 3 months for those treated by radiation alone. In addition, a greater proportion of the surgically treated patients were benefitted neurologically (70%) compared with those treated by radiation (45%). With the development of effective surgical treatment for spinal metastases, early consideration for surgical treatment (before radiation) should be considered in selected patients. Preoperative spinal angiography and embolization are recommended whenever feasible to minimize intraoperative blood loss.

Treatment of neoplastic spinal cord compression: results of a prospective study

Currently, external radiation and steroid therapy are used in most patients with neoplastic spinal cord compression. Surgery is generally used to treat those who do not respond to radiation therapy. To determine the role of de novo surgery in patients with spinal metastases, a prospective study was undertaken. Over a 4 1/2-year period, the cases of 54 patients with radiologically documented spinal metastases were studied. The sites of tumor origin included soft tissue sarcoma (8 patients), kidney (6 patients), lung (5 patients), breast (5 patients), spine (6 patients), unknown primary site (6 patients), and others (18 patients). Sites of compression included the cervical spine segments in 15 patients, thoracic segments in 23, lumbar in 14, and sacral in 2. Before surgery, 24 patients (44%) were nonambulatory. Three surgical approaches were used: anterior vertebral body resection in 45 patients, laminectomy in 7, and lateral osteotomy in 2. After surgery, 37 patients received external radiation therapy. All patients improved (became ambulatory) after surgery, with 23 of 25 patients surviving at 2 years continuing to be ambulatory. The 30-day mortality rate was 6% (three patients); eight patients (15%) sustained various surgical complications. These results are superior to those reported after external radiation therapy and steroids alone, and they support the concept that de novo surgery be considered in selected patients with spinal metastases.

Spondylectomy for malignant tumors of the spine

Spondylectomy is the complete surgical removal of all parts of one or more vertebrae above the sacrum. We report our initial experience with spondylectomy in eight patients with malignant tumors of the spine operated on over a 7-year period (1980 to 1986). Four patients had primary neoplasms of the spine, and four others had solitary metastases to the vertebrae. Following surgery, five patients underwent radiation therapy (RT) and chemotherapy depending on histology of the tumor. Radiographic confirmation of tumor resection was obtained on all patients. Pain relief was noted in all patients, and six patients with preoperative neurological deficits improved. There was no surgical mortality, and one patient developed wound dehiscence following surgery. Six of the eight patients are alive with a median follow-up of 36 months, and local control was achieved in six of the eight patients. These preliminary data suggest that malignant tumors of the spine can be completely resected using a staged approach. In potentially responsive tumors, systemic chemotherapy is recommended between the two operations to reduce the risk of systemic dissemination.

Craniofacial resection for anterior skull base tumors

We present the results of treatment of 30 patients with anterior skull base tumors operated on over an 11-year period. At the time of surgery, intracranial invasion was present in 10 patients. Histology revealed epithelial tumors in 18 patients, sarcoma in 6, esthesioneuroblastoma in 4, and 2 miscellaneous histologies. The overall median survival was 5 years and varied according to histology and grade of tumor. Currently malignancies involving the skull base can be successfully resected using a craniofacial approach, with minimum operative mortality. Limited intracranial invasion need not necessarily represent a major contraindication of this procedure if morbidity can be kept to a minimum.

Craniofacial resections for tumors involving the base of the skull

Over a 10 year period, 42 patients with tumors involving the base of the skull underwent operation at our institution. Twenty-six patients had tumors involving the anterior fossa and cribriform plate, 3 patients had tumors involving the anterior fossa and orbit, 3 patients had invasion of the middle fossa, 5 patients had invasion of the temporal bone, and 5 patients had invasion of the clivus. A detailed analysis of the 26 patients who underwent craniofacial resection for tumors invading the anterior fossa cribriform plate region has been presented. Histologic studies revealed epithelial tumors in 18 patients, sarcoma in 6 patients, melanoma in one patient, and ossifying fibroma in one patient. The median survival in this group of patients was 60 months. Survival was influenced by histologic diagnosis. Malignant tumors involving the base of the skull can be successfully resected using a craniofacial approach with minimum morbidity and acceptable operative mortality as demonstrated in this experience. Unfavorable prognostic factors included massive intracranial extension, high grade tumor, and previous treatment failure.

Reoperation for brain metastases

We report the results of reoperation for brain metastases in 21 patients with recurrent tumors following initial successful resection. The tumor recurrences were local (original site) in 14 patients, and occurred at other sites in the brain in the remaining seven. Time to CNS recurrence ranged from 3 to 30 months. At time of repeat craniotomy, disease was limited to the CNS in 12 (57%) of the patients. Median survival following second craniotomy was 9 months, and the actuarial 2-year survival was 25%. Neurological improvement was seen in two thirds of the patients; the median duration of neurological improvement was 6 months. There was no mortality, and only one patient developed increased deficit following surgery. We conclude that repeat resection of brain metastases is an important therapeutic option in selected patients, and should be considered in symptomatic patients with accessible mass lesions before the use of other experimental treatment.

Surgical treatment of brain metastases from lung cancer

Thirty-five patients underwent surgical resection of brain metastases from non-oat-cell lung cancer between 1978 and 1981. Twenty-nine patients received postoperative radiation therapy to the brain. Twenty-three patients were male and 12 were female. Intracranial metastases occurred as the initial symptom of malignancy in 14 patients, and at varying periods following treatment of the primary tumor in 21 patients. The primary tumor and involved nodes were treated by definitive surgery in 18 patients, palliative resection and interstitial radiation in 10 patients, and by radiation therapy or chemotherapy alone in seven patients. The overall median survival time was 14 months. Favorable prognostic variables included: 1) absence of local or systemic disease at time of craniotomy (median 23 months survival time); 2) aggressive treatment of the primary tumor (median 18 months survival time); and 3) metachronous onset of brain metastases (median 15 months survival time). These survival data represent a considerable improvement over the historical 6 months median period of survival in such patients.

A transsternal approach to the upper thoracic vertebrae

An anterior surgical approach to the upper thoracic vertebrae has been described. A T-shaped skin incision is used, with the horizontal limb 1 cm above the clavicle, and the vertical limb extending in the midline over the body of the sternum. A portion of the manubrium sterni, as well as the medial third of the clavicle, is resected; the avacular tissue plane between the carotid sheath laterally and the trachea and esophagus medially is developed to reach the prevertebral space. After surgery, immediate fusion is performed using the clavicle and manubrium. This procedure is well tolerated, and was associated with minimal morbidity and no mortality in a series of seven patients.

Chemotherapy of recurrent esthesioneuroblastoma. Case report and review of the literature

Esthesioneuroblastoma is a rare epithelial tumor of the nasal olfactory mucosa. Its clinical course is characterized by indolent growth and persistent local recurrence and occasional distant metastases despite attempts at cure. Our report documents the response of a patient to a cisplatin-based drug combination and reviews the English-language literature of 25 patients treated with chemotherapy. We conclude that this tumor is sensitive to several different combinations and suggest guidelines for the use of chemotherapy in advanced or metastatic esthesioneuroblastoma.

Osteogenic sarcoma of the skull. A clinicopathologic study of 19 patients

The authors studied 19 patients with well documented osteogenic sarcomas arising in the skull, which represent 1.6% of all osteogenic sarcomas registered during a 60-year period (1921-1981). Ten sarcomas were primary, de novo tumors. Nine others developed secondary osteogenic sarcomas; among these, six arose as a complication of Paget's disease, two followed irradiation, and one was associated with pre-existent fibrous dysplasia. The sarcomas arose in equal proportion in both sexes with the men being much older (mean age, 44 years) as compared to the women (mean age, 31 years). Patients with de novo osteogenic sarcomas were considerably younger than those with secondary lesions. Osteoblastic osteogenic sarcoma was by far the most common histologic variant in both the primary and the Paget's sarcomas. None of the patients with Paget's sarcoma lived longer than 1 year; the median survival here was 4 months. Patients with de novo osteogenic sarcomas fared much better and there are four long-term survivors (longer than 3 years) who are currently disease-free.

Supratentorial recurrences in medulloblastoma

Four children with medulloblastoma had massive supratentorial recurrences in the region of the cribriform plate after adequate craniospinal irradiation. The pathogenesis of these recurrences is probably related to underdosage to this region by shielding of the eyes. This hypothesis was corroborated by autopsy findings in two other patients in whom subfrontal implants were histologically different from recurrences elsewhere. Two possible solutions to avoid this problem in the future are suggested.

Treatment of odontoid fractures in cancer patients

A series of 18 patients with odontoid fractures due to metastatic cancer were treated at Memorial Sloan-Kettering Cancer Center between 1974--1980. The primary source of cancer was breast (12 cases), lung (two cases), nasopharynx (one case), multiple myeloma (one case), colon (one case), and rhabdomyosarcoma (one case). The clinical features consisted of severe neck pain and neck stiffness in 17 patients; signs of cord compression were noted in only four patients. Tomography and computerized tomography were useful in identifying both the osseous and soft-tissue involvement by tumor. Initial treatment in all patients except those with myelopathy consisted of high-dose steroids, and immobilization in a hard collar. Ten patients were treated with radiation therapy alone; six patients underwent surgical fusion (four before and two after radiation therapy); and two patients died before completion of treatment. Conservatively treated patients were allowed to walk with the support of only a collar following radiation therapy. We believe that the initial management of patients with odontoid fractures secondary to cancer should be high-dose steroids and radiation therapy, unless displacement is marked. Assessment for surgical fusion should be made following radiation therapy, since conservative treatment may suffice in most patients. Early recognition is important so that treatment can be instituted before C1--2 subluxation becomes severe.

The combined neurosurgical-thoracic management of superior sulcus tumors

Thirty patients with superior sulcus carcinoma were prospectively evaluated over an 18-month period. All patients underwent complete neuroradiological evaluation by computed tomography (CT) and myelography. Prior to operation, brachial plexopathy was noted in 20 patients (67%), and invasion of the spine in eight (27%). Using a team approach, gross total resection of tumor was achieved in 17 of 26 patients (65%) undergoing thoracotomy. There was no operative mortality. The use of a team approach allows extended surgical resection, especially when the spine is involved. In patients presenting with brachial plexopathy or cord compression, de novo surgery before radiation may provide better long-term palliation and pain relief.