Metastatic spine disease: epidemiology, pathophysiology, and evaluation of patients

Is Kiva implant advantageous to balloon kyphoplasty in treating osteolytic metastasis to the spine? Comparison of 2 percutaneous minimal invasive spine techniques: a prospective randomized controlled short-term study

STUDY DESIGN

Prospective, parallel-group, controlled, comparative randomized study.

OBJECTIVE

To compare cement leakage rate and efficacy for vertebral body restoration of balloon kyphoplasty (BK) versus Kiva novel implant with polymethylmethacrylate (PMMA) for treating osteolytic vertebral body metastasis.

SUMMARY OF BACKGROUND DATA

Minimally invasively vertebral augmentation techniques with PMMA are mostly performed for treating osteoporotic compression fractures. The Kiva implant with PMMA offers better vertebral body restoration and less PMMA leakage than BK in osteoporotic fractures. No previous study compared leakage rate and efficacy for vertebral body restoration in traditional BK and Kiva with PMMA in osteolytic vertebral body metastases.

METHODS

This study examined 23 patients (71 ± 13 yr) with 41 osteolytic vertebral bodies, who received Kiva with low viscosity PMMA and 24 patients (70 ± 11 yr) with 43 vertebral body osteolyses, who were reinforced with BK and high viscosity PMMA. All osteolyses were graded as Tomita 1 to 3. Anterior vertebral body height ratio (AVBHr), posterior vertebral body height ratio (PVBHr), and middle vertebral body height ratio (MVBHr), Gardner kyphotic deformity, PMMA leakage and were measured and compared between the groups. Visual analogue scale and Oswestry Disability Index were used for functional outcome evaluation.

RESULTS

No patient survived after 3 months. Asymptomatic PMMA leakage occurred in 4 (9.3%) vertebrae in the BK group solely (2 to the spinal canal, in Tomita grade 3 osteolysis) Anterior, posterior and middle vertebral body height ratio, Gardner angle improved insignificantly in both groups. Visual anlogue scale and Oswestry Disability Index improved postoperatively similarly in both groups (P < 0.001).

CONCLUSION

BK and Kiva provided equally significant spinal pain relief in patients with cancer with osteolytic metastasis. The absence of cement leakage in the Kiva group and absence of neurological complication in the BK group leakages reflects the safety of both augmentation techniques even in significant osteolysis. The lack of cement leakage in the Kiva cases, although low viscosity PMMA was used, increases this implant safety in augmenting severely destructed thoracolumbar vertebrae and sacrum from osteolytic metastasis.

LEVEL OF EVIDENCE

1.

Evaluation and treatment of spinal metastatic disease

With the increased survival of oncologic patients, evaluation and management of patients with spinal metastasis is crucial to reducing morbidity and maximizing function. In this chapter, we present some guidelines for the initial systematic evaluation of patients with spinal lesions, as well as the risks, benefits, and alternatives to nonoperative and operative management of metastatic spinal disease, and the overall survival of these patients.

[Prognosis scores for spinal metastases]

Advances in early detection and therapy of spinal metastasis have improved life expectancy of patients with various tumor entities. However, this and the demographic development have led to an increased risk for developing spinal metastases. Numerous prognostic factors have been determined to allow an assessment of outcome and survival time of patients with metastatic spinal tumors. The implementation of these factors into different scoring systems has been encouraging in the decision making process of spinal surgery. This overview highlights some of the most important prognostic factors and scores which may facilitate surgical considerations.

Intraoperative and percutaneous iridium-192 high-dose-rate brachytherapy for previously irradiated lesions of the spine

PURPOSE

Advances in stereotactic radiosurgery have improved local control of spine metastases, but local failure is still a problem and repeat irradiation is limited by normal tissue tolerance. A novel high-dose-rate (HDR) brachytherapy technique has been developed to treat these previously irradiated lesions.

METHODS AND MATERIALS

Five patients with progressive disease at previously irradiated sites in the spine who were not amenable to further external beam radiation were treated. Catheters were placed intraoperatively in 2 patients and percutaneously implanted in 3 patients with image-guided techniques. Conformal plans were generated to deliver dose to target tissues and spare critical structures. Patients received single-fraction treatment using HDR iridium-192 brachytherapy.

RESULTS

Median dose was 14 Gy (range, 12-18 Gy) with a median gross total volume D90 of 75% (range, 31-94%); spinal cord/cauda equina dose constraints were met. At a median followup of 9 months, no local progression of disease has been observed. Four patients had reduction in pain 1-4 weeks after treatment. No brachytherapy-related complications have been observed.

CONCLUSIONS

Intraoperative and percutaneous iridium-192 HDR spine brachytherapy techniques were not associated with complications or acute toxicity. There has been no local progression at treated sites, and most patients experienced reduction in cancer-related pain.

Treatment of cervical vertebral (C1) metastasis of lung cancer with radiotherapy: A case report

The present study discusses a patient with C1 vertebral metastasis from adenocarcinoma of the left lung. The patient was a 31-year-old female suffering from neck pain who was referred by her physician. Magnetic resonance imaging revealed osteolytic destruction of the C1 vertebra. Chest and computed tomographic scans revealed lung carcinoma changes involving the left lung. A biopsy confirmed adenocarcinoma of the left lung. Abnormal activity was present in the cervical spine (C1) region in a radionuclide bone scan. The patient was then referred to an oncologist. The spine was stabilized with a rigid collar and a course of radiation therapy and pain medication was initiated immediately. At the 9-month follow-up examination, there was no evidence of progression on the MRI scans and the main neck symptoms had disappeared. At present, the overall survival (OS) time is 11 months. Patients complaining of new onset back or neck pain should be assumed to have vertebral metastasis until proven otherwise. Trivial trauma should be taken seriously in these cases and investigated with appropriate clinical, laboratory and imaging examinations.

Spinal metastasis in thyroid cancer

BACKGROUND

Thyroid carcinoma generally responds well to treatment and spinal metastasis is an uncommon feature. Many studies have looked at the management of spinal metastasis and proposed treatments, plans and algorithms. These range from well-established methods to potentially novel alternatives including bisphosphonates and vascular endothelial growth factor (VEGF) therapy, amongst others.The purposes of this systematic review of the literature are twofold. Firstly we sought to analyse the proposed management options in the literature. Then, secondly, we endeavoured to make recommendations that might improve the prognosis of patients with spinal metastasis from thyroid carcinomas.

METHODS

We conducted an extensive electronic literature review regarding the management of spinal metastasis of thyroid cancer.

RESULTS

We found that there is a tangible lack of studies specifically analysing the management of spinal metastasis in thyroid cancer. Our results show that there are palliative and curative options in the management of spinal metastasis, in the forms of radioiodine ablation, surgery, selective embolisation, bisphosphonates and more recently the VEGF receptor targets.

CONCLUSIONS

The management of spinal metastasis from thyroid cancer should be multi-disciplinary. There is an absence; it seems, of a definitive protocol for treatment. Research shows increased survival with 131I avidity and complete bone metastasis resection. Early detection and treatment therefore are crucial. Studies suggest in those patients below the age of 45 years that treatment should be aggressive, and aim for cure. In those patients in whom curative treatment is not an option, palliative treatments are available.

Spinal metastasis in head and neck cancer

Background

The incidence of head and neck cancer is relatively low in developed countries and highest in South East Asia. Notwithstanding advances in surgery and radiotherapy over the past several decades, the 5-year survival rate for head and neck cancer has stagnated and remains at 50–55%. This is due, in large part, to both regional and distant disease spread, including spinal metastasis. Spinal metastasis from head and neck cancer is rare, has a poor prognosis and can significantly impede end-stage quality of life; normally only palliative care is given.

This study aims to conduct a systematic review of the evidence available on management of spinal metastasis from head and neck cancer and to use such evidence to draw up guiding principles in the management of the distant spread.

Methods

Systematic review of the electronic literature was conducted regarding the management of spinal metastasis of head and neck malignancies.

Results

Due to the exceptional rarity of head and neck cancers metastasizing to the spine, there is a paucity of good randomized controlled trials into the management of spinal metastasis. This review produced only 12 case studies/reports and 2 small retrospective cohort studies that lacked appropriate controls.

Conclusion

Management should aim to improve end-stage quality of life and maintain neurological function. This review has found that radiotherapy +/− medical adjuvant is considered the principle treatment of spinal metastasis of head and neck cancers.

There is an absence of a definitive treatment protocol for head and neck cancer spinal metastasis. Our failure to find and cite high-quality scientific evidence only serves to stress the need for good quality research in this area.

Three-dimensional C-arm computed tomography reformation combined with fluoroscopic-guided sacroplasty for sacral metastases

The aim of this retrospective study was to evaluate a sacroplasty technique, using three-dimensional C-arm CT reformation combined with fluoroscopic guidance for patients with severe painful sacral metastases. We studied the data of seven patients (average age 55.7 years) treated through trans-sacroiliac joint approach with the technique. Patients with additional thoracolumbar osteolytic metastases (five out of seven) also received concomitant vertebroplasty accordingly. Subjective significant pain relief was reported with visual analogue scale reduction ≥4 in all seven patients at 1 month after procedure, six out of seven at 3 months, and five out of six at 6 months. Pain recurrence was reported in two patients at 3 and 6 months follow-up, respectively, associated with their clinical evidence of tumor progression. One patient died from underlying disease unrelated with the procedure. Sacroplasty under three-dimensional C-arm CT reformation combined with fluoroscopic guidance was a feasible, safe, and minimally invasive procedure that could provide both the precise control of needle placement and cement injection with one imaging system.

Metastatic disease in the thoracic and lumbar spine: evaluation and management

Spinal metastases are found in most patients who die of cancer. The number of patients with symptomatic spinal metastases likely will increase as therapy for the primary disease improves and as cardiovascular mortality decreases. Understanding the epidemiology of metastatic spine disease and its presentation is essential to developing a diagnostic strategy. Treatment may involve chemotherapy, corticosteroids, radiotherapy, surgery, and/or percutaneous procedures (eg, vertebroplasty, kyphoplasty). A rational treatment plan can help improve quality of life, preserve neurologic function, and prolong survival.

Image-Guided-Radiotherapy Retreatment of Spine Metastasis: A Case Report and Radiobiological Evaluation

Aims and background

The present case report describes vertebral metastasis retreatment using kilovoltage cone-beam computed tomography (CBCT) for setup error correction, in order to improve target irradiation and prevent spinal cord toxicity. We evaluated the feasibility of the second radiation therapy course on the overlapping treatment volume.

Methods and study design

A patient with metastatic kidney cancer, previously treated to the tenth dorsal vertebra with conventional radiation planning (21 Gy; 3 × 7 Gy), underwent retreatment. In order to deliver 30 Gy (15 × 2 Gy) to the target volume with the second irradiation, we evaluated the residual dose that could be received by the spinal cord. We calculated the biologically effective dose according to the linear-quadratic model, using an α/β ratio of 2 Gy. A 3-dimensional conformal plan was generated; CBCT imaging was used to ensure accurate repositioning.

Results

A total of 15 CBCT scans were performed; the mean setup corrections in the lateral, longitudinal and vertical directions were 3.38 mm (SD 2.09; range, −0.2 mm ÷ 7.6 mm), 2.13 mm (SD 3.38; range, −5.9 mm ÷ 6 mm), and −1.28 mm (SD 2.02; range, −7.1 mm ÷ 0.3 mm), respectively.

Conclusion

Image-guided radiotherapy is an alternative approach for the retreatment of spine tumors; it ensures accurate patient setup correction and high-precision treatment delivery, which are required for target volumes very close to critical structures. Free full text available at www.tumorionline.it

Diagnosis and management of metastatic spine disease. A review

With continued growth of the elderly population and improvements in cancer therapies, the number of patients with symptomatic spinal metastases is likely to increase, and this is a condition that commonly leads to debilitating neurological dysfunction and pain. Advancements in surgical techniques of resection and spinal reconstruction, improvements in clinical outcomes following various treatment modalities, generally increased overall survival in patients with metastatic spine disease, and a recent randomized trial by Patchell and colleagues demonstrating the superiority of a combined surgical/radiotherapeutic approach over a radiotherapy-only strategy have led many to suggest increasingly aggressive interventions for patients with such lesions. Optimal management of spinal metastases encompasses numerous medical specialties, including neurosurgery, orthopedic surgery, medical and radiation oncology, radiology, and rehabilitation medicine. In this review, the clinical presentation, diagnosis, and management of spinal metastatic disease are discussed. Ultimately, the goal of treatment in patients with spinal metastases remains palliative, and clinical judgment is required to select the appropriate patients for surgical intervention.

Spine metastases: current treatments and future directions

Spinal metastases are the most frequently encountered spinal tumour and can affect up to 50% of cancer patients. Both the incidence and prevalence of metastases are thought to be rising due to better detection and treatment options of the systemic malignancy resulting in increased patient survival. Further, the development and access to newer imaging modalities have resulted in easier screening and diagnosis of spine metastases. Current evidence suggests that pain, neurological symptoms and quality of life are all improved if patients with spine metastases are treated early and aggressively. However, selection of the appropriate therapy depends on several factors including primary histology, extent of the systemic disease, existing co-morbidities, prior treatment modalities, patient age and performance status, predicted life expectancy and available resources. This article reviews the currently available therapeutic options for spinal metastases including conventional external beam radiation therapy, open surgical decompression and stabilisation, vertebral augmentation and other minimally invasive surgery (MIS) options, stereotactic spine radiosurgery, bisphosphonates, systemic radioisotopes and chemotherapy. An algorithm for the management of spine metastases is also proposed. It outlines a multidisciplinary and integrated approach to these patients and it is hoped that this along with future advances and research will result in improved patient care and outcomes.

Phase I trial of vertebral intracavitary cement and samarium (VICS): novel technique for treatment of painful vertebral metastasis

PURPOSE

Kyphoplasty is an effective procedure to alleviate pain in vertebral metastases. However, it has no proven anticancer activity. Samarium-153-ethylene diamine tetramethylene phosphonate ((153)Sm-EDTMP) is used for palliative treatment of bone metastases. A standard dose of 1 mCi/kg is administrated intravenously. The present study was conducted to determine the feasibility of intravertebral administration of (153)Sm with kyphoplasty.

METHODS AND MATERIALS

A total of 33 procedures were performed in 26 patients. Of these 26 patients, 7 underwent procedures performed at two vertebral levels. The mean age of the cohort was 64 years (range, 33-86). The kyphoplasty procedure was performed using a known protocol; 1-4 mCi of (153)Sm was admixed with the bone cement and administered under tight radiation safety measures. Serial nuclear body scans were obtained. Pain assessment was evaluated using a visual analog pain score.

RESULTS

All patients tolerated the procedure well. No procedure-related morbidities were noted. No significant change had occurred in the blood counts at 1 month after the procedure. One case was not technically satisfactory. Nuclear scans revealed clear radiotracer uptake in the other 32 vertebrae injected. Except for the first patient, no radiation leakage was encountered. The mean pain score using the visual analog scale improved from 8.6 before to 2.8 after the procedure (p < .0001). Follow-up bone scans demonstrated a 43% decrease in the tracer uptake.

CONCLUSION

The results of our study have shown that the combination of intravertebral administration of (153)Sm and kyphoplasty is well tolerated with adequate pain control. No hematologic adverse effects were found. A reduction of the bone scan tracer uptake was observed in the injected vertebrae. Longer follow-up is needed to study the antineoplastic effect of the procedure.

Percutaneous tumor curettage and interstitial delivery of samarium-153 coupled with kyphoplasty for treatment of vertebral metastases

Object

The object of this study was to investigate the use of a minimally invasive technique for treating metastatic tumors of the vertebral body, aimed at relieving pain, preventing further tumor growth, and minimizing the adverse effects of systemic use of samarium-153 (153Sm).

Methods

The procedure is performed in the same fashion as a kyphoplasty, using a unilateral extrapedicular approach under local anesthesia/mild general sedation, with the patient in the lateral decubitus position. The tumor is accessed as in a standard kyphoplasty. The side is chosen according to the location of the metastasis. Prior to inflation of the balloon the tumor is debulked by percutaneous curettage. Balloon inflation is carried out as per standard kyphoplasty in an attempt to create a larger space and reduce a possible kyphotic deformity. Three mCi of 153Sm-EDTMP (ethylenediaminetetramethylenephosphonic acid) is then mixed with bone cement (polymethylmethacrylate) and injected into the void created by the balloon tamp.

Results

Twenty-four procedures were performed in 19 patients. There was reliable and reproducible delivery of the radiolabeled 153Sm-EDTMP to the metastatic site, without spillage. The procedure was safe. There were no procedure-related complications. There was no hematological toxicity with the low doses of 153Sm used. Pain improved in all patients. The long-term results related to tumor control continue to be investigated.

Conclusions

Combined percutaneous debulking of confined vertebral metastases and administration of local 153Sm is feasible and safe. Furthermore, this technique leads to immediate relief of cancer-related pain and may help prevent or slow down the progression of vertebral metastatic tumors.

Lumbar tumor resections and management

More than one-third of patients with cancer have vertebral metastases found at autopsy. Primary and metastatic tumors to the spinal column can lead to pain, instability, and neurologic deficit. Symptomatic lesions are most prevalent in the thoracic spine (70%), followed by the lumbar spine (20%) and cervical spine (10%). Lesions in larger vertebral bodies tend to be asymptomatic given the increased ratio between the diameter of the spinal canal and the traversing nerve roots.

Solitary vertebral metastasis

As survival time increases for many cancers, it is likely that the incidence and prevalence of spinal metastases will increase also. Given that most patients first present with solitary lesions in the spine, proper initial diagnosis and management are of paramount importance in minimizing pain, improving neurologic function, and potentially lengthening survival. Although pain control and standard radiation are still used, spinal stereotactic radiosurgery, vertebroplasty and kyphoplasty, and spinal cord decompression and fusion are now consistently used in aggressive management and offer exciting preliminary results.

CyberKnife radiosurgery for malignant spinal tumors: characterization of well-suited patients

STUDY DESIGN

A prospective interventional case-series study.

OBJECTIVE

To provide clinical results of CyberKnife fiducial-free spinal radiosurgery. The study focused on patients with no more than 2 malignant spinal tumors.

SUMMARY OF BACKGROUND DATA

Progress in frameless radiosurgical technology has enabled the application of radiosurgery to the spine. The CyberKnife System has been used extensively for spine radiosurgery. Until recently, the system required metallic fiducial implants for precise target tracking. Fiducial-free spinal radiosurgery with the CyberKnife has recently become possible, but until now clinical results obtained with this method had been limited.

METHODS

From August 2005 until October 2007, a consecutive series of 102 patients with a total of 134 malignant spinal tumors were selected for single-fraction, fiducial-free CyberKnife radiosurgery (CKRS). The study was limited to patients with a maximum of 2 tumors. Malignant primaries included breast cancer in 23 (22.6%) patients, renal cancer in 20 (19.6%) patients, gastro-intestinal cancers in 12 (11.8%) patients, prostate cancer each in 12 (11.8%) patients, lung cancer in 9 (8.9%) patients, sarcomas in 7 (6.9%) patients. A variety of other malignant tumors were found in 19 (18.6%) patients. Patients with spinal cord compression or evidence of myelopathy were excluded. The sequential neurologic status was recorded. Tumor-associated spinal pain was prospectively scored according to the visual analogue scale (VAS).

RESULTS

Of 102 individuals, 22 (21.6%) died due to progression of their systemic disease. Mean survival after CKRS was 1.4 years (CI: 1.2-1.6). Karnofsky performance score was the only independent predictor of survival after radiosurgery on log-rank test (P < 0.0001), and on Cox regression analysis (hazard ratio, 0.864, P < 0.0001, CI: 0.809-0.922). Median survival after initial tumor diagnosis was 18.4 years (CI: 15.1-23.4). Two (2%) patients suffered complications after radiosurgery; a tumor hemorrhage occurred in one, and another developed spinal instability. These and 2 other patients were stabilized by kyphoplasty. Neurotoxicity or myelopathy was not observed. Local tumor control 15 months after CKRS was 98% (95% CI: 89-99%). Tumor-associated pain was observed in 52 (51%) patients. In these patients the median pretreatment pain score of VAS = 7 (95% CI: 6-7) was significantly reduced to VAS = 1 (95% CI: 4-6) (P < 0.001) within 1 week after CKRS. Analysis of variance identified the initial pain score as the only significant variable to predict pain reduction after CKRS (P < 0.03). Pain recurrence in correlation with tumor recurrence was observed for 3 (6%) patients.

CONCLUSION

Spinal radiosurgery with the CyberKnife technology is a nonivasive, safe, and effective treatment method for patients with 1 or 2 small spinal malignant tumors. The best benefit of the treatment can be expected in patients with good to excellent clinical condition and patients with severe tumor associated pain.

Review of spinal radiosurgery: a minimally invasive approach for the treatment of spinal and paraspinal metastases

Intracranial radiosurgery has been proved effective for the treatment of brain metastasis. The treatment of paraspinal and spinal metastasis with spinal radiosurgery represents a natural extension of the principles of intracranial radiosurgery. However, spinal radiosurgery is a far more complicated process than intracranial radiosurgery. Larger treatment volumes, numerous organs at risk, and the inability to utilize rigid, frame-based immobilization all contribute to the substantially more complex process of spinal radiosurgery.

Beyond the convenience of a shorter duration of treatment for the patient, spinal radiosurgery affords a greater biological equivalent dose to a metastatic lesion than conventional radiotherapy fractionation schemes. This appears to translate into a high rate of tumor control and fast pain relief for patients. The minimally invasive nature of this approach is consistent with trends in open spinal surgery and helps to maintain or improve a patient's quality of life. Spinal radiosurgery has expanded the neurosurgical treatment armamentarium for patients with spinal and paraspinal metastasis.

A Case of Vertebral Metastasis With Pathologic C2 Fracture

OBJECTIVE

This report discusses a patient with a pathologic fracture of the C2 vertebra secondary to osteolytic metastasis from squamous cell carcinoma of the lung.

CLINICAL FEATURES

The patient was a 68-year-old man with a chief complaint of neck pain who was referred by his physician to a chiropractic office. The initial onset of neck pain began after a forceful sneeze that resulted in a sensation of "a twig snapping" in the neck. Radiographs revealed osteolytic destruction and pathologic fracture of the C2 spinous process.

INTERVENTION AND OUTCOME

The patient was referred back to his primary care physician, who then referred him to an oncologist, who immediately initiated a course of radiation therapy and pain medication. Palliative care by the chiropractor consisted of soft tissue massage of the cervical spine musculature to treat associated muscle spasms and pain. The patient responded well to gentle myofascial therapy. However, the osteolytic destruction of the C2 posterior elements progressed, resulting in an unstable subluxation of C2 and associated cord compression. The spine was stabilized with a rigid collar, but the metastatic destruction progressed, eventually resulting in quadriplegia and subsequent death from respiratory distress.

CONCLUSION

Patients with a history of cancer complaining of new onset of back or neck pain should be assumed to have vertebral metastasis until proven otherwise. Trivial trauma should be taken seriously in these cases and investigated with appropriate clinical, laboratory, and imaging examinations. Vertebral malignancies may be a contraindication to spinal manipulation; however, the chiropractic physician plays a significant role in early detection and diagnosis.

Radiosurgery for spinal metastases: clinical experience in 500 cases from a single institution

STUDY DESIGN

A prospective nonrandomized, longitudinal cohort study.

OBJECTIVE

To evaluate the clinical outcomes of single-fraction radiosurgery as part of the management of metastatic spine tumors.

SUMMARY OF BACKGROUND DATA

The role of stereotactic radiosurgery for the treatment of spinal lesions has previously been limited by the availability of effective target immobilization and target tracking devices. Large clinical experience with spinal radiosurgery to properly assess clinical experience has previously been limited.

METHODS

A cohort of 500 cases of spinal metastases underwent radiosurgery. Ages ranged from 18 to 85 years (mean 56). Lesion location included 73 cervical, 212 thoracic, 112 lumbar, and 103 sacral.

RESULTS

The maximum intratumoral dose ranged from 12.5 to 25 Gy (mean 20). Tumor volume ranged from 0.20 to 264 mL (mean 46). Long-term pain improvement occurred in 290 of 336 cases (86%). Long-term tumor control was demonstrated in 90% of lesions treated with radiosurgery as a primary treatment modality and in 88% of lesions treated for radiographic tumor progression. Twenty-seven of 32 cases (84%) with a progressive neurologic deficit before treatment experienced at least some clinical improvement.

CONCLUSIONS

The results indicate the potential of radiosurgery in the treatment of patients with spinal metastases, especially those with solitary sites of spine involvement, to improve long-term palliation.

Development of a model with which to predict the life expectancy of patients with spinal epidural metastasis

BACKGROUND

The surgical treatment of spinal epidural metastasis is evolving. To be a surgical candidate, a patient should have a life expectancy of at least 3 months. Estimation of survival by experienced specialists has proven to be unreliable.

METHODS

The Cox proportional hazards model was used to make a prediction model. To validate the model, Efron optimism correction by bootstrapping was performed. Retrospective data of patients treated for a spinal metastasis were used. Possible predictive factors were defined based on clinical experience and the literature. Statistical methods and clinical knowledge were also used to reveal an optimal set of predictors of survival. Data from patients treated at the Department of Radiation Oncology for spinal metastasis between 1998 and 2005 were evaluated.

RESULTS

The case notes of 219 patients form the base of this study. In the final model, only 5 variables were required to predict the survival of a patient with spinal metastasis: sex, location of the primary lesion, intentional curative treatment of the primary tumor, cervical location of the spinal metastasis, and Karnofsky performance score. Examples with different predictors are given. The R(2) (N) index of Nagelkerke was 0.36 (95% confidence interval [95% CI], 0.28-0.48) and the c-index 0.72 (95% CI, 0.68-0.77).

CONCLUSIONS

A reliable and simple model with which to predict the survival of a patient with spinal epidural metastasis is presented. Without the need for extensive investigations, survival can be predicted and only 5 easily obtainable parameters are required.

Incidence of unusual and clinically significant histopathological findings in routine discectomy

OBJECT

Routine histopathological examination of discectomy specimens remains common practice in many hospitals, although it rarely detects unsuspected clinically significant disease. Controversy exists as to the effectiveness of this practice. The objectives of this study were to compare the authors' experience with a review of the literature.

METHODS

In a retrospective database analysis the authors identified all intervertebral disc specimens obtained during spinal procedures over an 8-year period (1996-2004). Cases of benign (nonneoplastic and noninfectious) indications for surgery were included in the study, whereas cases of nonbenign indications were excluded. The final pathological diagnoses were reviewed, and a chart review was performed to determine whether any unexpected findings affected subsequent patient care. A total of 1858 discectomy specimens were identified: 1775 of these were obtained in 1719 routine discectomy procedures. Unexpected histopathological findings were identified in four cases, and none was clinically significant.

CONCLUSIONS

Routine histopathological examination of disc specimens is not justified. The decision to send specimens for pathological examination should be determined on a case-by-case basis after consideration of the clinical presentation, results of laboratory and imaging studies, and intraoperative findings.

Diagnosis and management of metastatic spine disease

Spinal metastases are a significant source of morbidity in patients with systemic cancer. Roughly 30% of patients with cancer develop symptomatic spinal metastases during the course of their illness, and up to 90% of cancer patients possess metastatic lesions within the spine at the time of death with advances in the treatment of systemic disease, survival in such patients has increased. This factor combined with improved imaging modalities will undoubtedly increase the incidence in which spinal metastases are encountered by physicians. In this review, the authors not only attempt to present the myriad ways in which patient with spinal metastases present, but also the means by which they are currently diagnosed and managed. In addition, we propose a simple algorithm to aid in deciding which patients are ideally treated medically and which patients may benefit from surgery.

Multiple myeloma of the cervical spine: treatment strategies for pain and spinal instability

OBJECT

Metastases of multiple myeloma often occur in the cervical spine. These metastases may cause pain and associated spinal instability. The authors report the results of radiotherapy and surgical treatment for myeloma involving the cervical spine. The results of radiation therapy for multiple myeloma metastases to the cervical spine that cause clinical or radiographically documented instability have not been reported previously.

METHODS

A retrospective chart review of patients with multiple myeloma metastases to the cervical spine was undertaken. Between 1993 and 2005, 35 patients were treated with external-beam radiation and/or surgical stabilization at the University of Texas M. D. Anderson Cancer Center in Houston, Texas. Nineteen of 20 patients with sufficient follow-up data experienced resolution of their pain when treated with radiation without surgical intervention. Twenty-three patients had evidence of spinal instability on radiographic images; 15 of these were treated with radiation alone. Of these, 10 had sufficient follow-up data, and none showed any clinical progression of instability. Radiographic follow-up images demonstrated an arrest of further progression of instability and, in some cases, healing of pathological fractures by means of radiation alone.

CONCLUSIONS

The results of this series suggest that, in selected cases, external-beam radiation for multiple myeloma metastases to the cervical spine is an effective palliative treatment, even in cases involving clinical or radiographically documented instability.

Radiosurgery for the treatment of spinal melanoma metastases

BACKGROUND

The role of stereotactic radiosurgery in treating metastatic melanoma involving the spine has previously been limited. Conventional external beam radiotherapy lacks the precision to allow delivery of large single-fraction doses of radiation and simultaneously to limit the dose delivered to radiosensitive structures such as the spinal cord. This study evaluated the clinical efficacy of radiosurgery for the treatment of melanoma spinal metastases in 28 patients.

METHODS

Thirty-six melanoma spine metastases were treated with a single-session radiosurgery technique (1 cervical, 11 thoracic, 13 lumbar, and 11 sacral) with a follow-up period of 3-43 months (median 13 months). Tumor volume ranged from 4.1 to 153 cm3 (mean 47.6 cm3). Twenty-three of the 36 lesions had received prior external beam irradiation.

RESULTS

Maximum tumor dose was maintained at 17.5-25 Gy (mean 21.7 Gy). Spinal cord volume receiving > 8 Gy ranged from 0.0 to 0.7 cm3 (mean 0.26 cm3); spinal canal volume at the cauda equina level receiving > 8 Gy ranged from 0.0 to 3.5 cm3 (mean 0.98 cm3). No radiation-induced toxicity occurred during the follow-up period. Axial and radicular pain improved in 27 of 28 patients (96%) who were treated primarily for pain. Long-term tumor control was seen in 3 of 4 cases treated primarily for radiographic tumor progression. Two patients went on to require open surgical intervention for tumor progression resulting in neurological deficit.

CONCLUSIONS

Spinal radiosurgery offers a therapeutic modality for the safe delivery of large dose fractions of radiation therapy in a single fraction for the management of spinal metastases in patients with advanced melanoma that are often poorly controlled with alternative conventional external beam radiation therapy, and is successful even in patients with previously irradiated lesions.

Radiosurgery for the treatment of spinal lung metastases

BACKGROUND

Spinal metastases are a common source of pain as well as neurologic deficit in patients with lung cancer. Metastases from lung cancer traditionally have been believed to be relatively responsive to radiation therapy. However, conventional external beam radiotherapy lacks the precision to allow delivery of large single-fraction doses of radiation and simultaneously limit the dose to radiosensitive structures such as the spinal cord. The current study evaluated the efficacy of single-fraction radiosurgery for the treatment of spinal lung cancer metastases.

METHODS

In the current prospective cohort evaluation, 87 lung cancer metastases to the spine in 77 patients were treated with a single-fraction radiosurgery technique with a follow-up period of 6 to 40 months (median, 12 months). The indication for radiosurgery treatment was pain in 73 cases, as a primary treatment modality in 7 cases, for radiographic tumor progression in 4 cases, and for progressive neurologic deficit in 3 cases.

RESULTS

Tumor volume ranged from 0.2 to 264 cm(3) (mean, 25.7 cm(3)). The maximum tumor dose was maintained at 15 to 25 grays (Gy) (mean, 20 Gy; median, 20 Gy). No radiation-induced toxicity occurred during the follow-up period. Long-term axial and radicular pain improvement occurred in 65 of 73 patients (89%) who were treated primarily for pain. Long-term radiographic tumor control was observed in all patients who underwent radiosurgery as their primary treatment modality or for radiographic tumor progression.

CONCLUSIONS

Spinal radiosurgery was found to be feasible, safe, and clinically effective for the treatment of spinal metastases from lung cancer. The results of the current study indicate the potential of radiosurgery in the treatment of patients with spinal lung metastases, especially those with solitary sites of spine involvement, to improve long-term palliation.

Surgical management of metastatic spine tumors

Recent advances in diagnostic tests and radiologic imaging, and the development of novel chemotherapeutic agents and radiation methods have greatly altered the treatment options in patients who have spinal tumors. Improvements in fundamental understanding of the mechanisms of bone metastases, developments in spinal instrumentation, and recent introduction of recombinant bone morphogenetic proteins for spinal reconstruction offer promising strategies in selected patients. Clear applications of the fundamental surgical oncology still apply to spinal tumors. This article considers recent advances in management of the metastatic tumors to the spine.

Expandable vertebral body replacement in patients with thoracolumbar spine tumors

INTRODUCTION

The objectives of surgical interventions for tumoral lesions of the spine include the establishment and improvement of tumor-related symptoms. Anterior tumor resection followed by reconstruction indicated if surgical treatment allowed a marginal removal of the tumor or could extend the individual survival rate in combination with adjuvant therapy options. Sufficient re-stabilization depends on adequate anterior column reconstruction. The purpose of this retrospective study was to present our experiences and results after anterior tumor resection followed by reconstruction with the expandable vertebral body replacement device (VBR, Ulrich, Germany) based on clinical application over 4 degrees years.

PATIENTS AND METHODS

We carried out an anterior tumor resection followed by reconstruction using an anterior extendable device in 32 patients with different spine tumors between 1996 and 2000. A retrospective evaluation was executed considering the patients medical records and radiological findings. Additionally, a clinical and radiological investigation of still living postoperative patients was carried out.

RESULTS

The mean surgical time of all evaluated patients was 317.2 min. The average blood loss was 1,272.5 ml. According to the Tokuhashi score, patients with a postoperative survival time of at least 12 months demonstrated a score value > or = 9 points. According to our evaluated patients group metastatic lesions of the spine represented the largest group (78.1%). The average survival rate of this group amounted to 18.4 months postoperatively. Considering primary tumors the average survival rate at the time of last re-examination amounted to 34.8 months postoperatively. Preoperative neurological pathologies were present in 12 patients (Frankel stage C-D). During the postoperative monitoring period 58.3% of the patients demonstrated an improvement in initial neurological findings. There were no intraoperative complications or perioperative deaths. Implant dislocations were not observed.

CONCLUSION

On account of the underlying, the anterior tumor resection with supplementary instrumentation represented a sufficient procedure in spinal tumor surgery. Adjuvant therapy can influence the postoperative survival period positively in addition to the surgical procedure. Following anterior tumor resection, extendable vertebral body replacements like the VBR device provide immediate spine stability by excellent defect adaptation. With regard to their intraoperative flexibility, expandable cages are more advantageous in contrast to non-expandable implants or bone grafts.

Single-fraction radiosurgery for the treatment of spinal breast metastases

BACKGROUND

The spine is the most common site of bony metastases in patients with osseous breast carcinoma metastases. Spine metastases are the source of significant pain and occasionally neurologic deficit in this patient population. Conventional external beam radiotherapy lacks the precision to allow delivery of large single-fraction doses of radiation and simultaneously limit the dose to radiosensitive structures such as the spinal cord. This study evaluated the clinical efficacy of the treatment of spinal breast carcinoma metastases with a single-fraction radiosurgical technique.

METHODS

In this prospective cohort evaluation, 68 breast carcinoma metastases to the spine in 50 patients were treated with a single-fraction radiosurgery technique with a follow-up period of 6-48 months, median 16 months. The most common indication for radiosurgery treatment was pain in 57 lesions, as a primary treatment modality in 8 patients, and for radiographic tumor progression, as a postsurgical boost, and for a progressive neurologic deficit in 1 patient each.

RESULTS

Tumor volume ranged from 0.8-197 cm3 (mean, 27.7 cm3). Maximum tumor dose was maintained at 15-22.5 Gy (mean, 19 Gy). No radiation-induced toxicity occurred during the follow-up period (6-48 mo). Long-term axial and radicular pain improvement occurred in 55 of 57 (96%) patients who were treated primarily for pain. Long-term radiographic tumor control was seen in all patients who underwent radiosurgery as their primary treatment modality, for radiographic tumor progression, or as a postsurgical treatment.

CONCLUSIONS

Spinal radiosurgery was found to be feasible, safe, and clinically effective for the treatment of spinal metastases from breast carcinoma. The results indicate the potential of radiosurgery in the treatment of patients with spinal breast metastases, especially those with solitary sites of spine involvement, to improve long-term palliation.