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

Patient-Reported Outcomes for Spine Oncology: A Narrative Review

Spine tumors, both primary and metastatic, impose significant morbidity and mortality on patients and physicians. Patient-reported outcomes are valuable tools to assess a patient's impression of their health status and enhance communication between physicians and patients. Various spine generic patient-reported outcome tools have traditionally been used but have not been validated in the spine tumor patient population. The Spine Oncology Study Group Outcome Questionnaire, which is disease-specific for the metastatic spine patient population, has been shown to have strong validity, even across multiple languages. Patient-Reported Outcomes Measurement Information System, which has recently been developed, employs computerized adaptive testing to assess multiple health domains. It has been shown to capture information in both generic and specific questionnaires and has the potential to be used as a universal tool in the spine oncology patient population. Further long-term studies, as well as, cross-cultural adaptations, are needed to validate Patient-Reported Outcomes Measurement Information System's applicability and effectiveness.

Interim analysis of patient-reported outcome compliance and dosimetry in a phase 3 randomized clinical trial of oesophagus-sparing spinal radiotherapy

BACKGROUND

The randomized clinical trial ESO-SPARE investigates if oesophagus-sparing radiotherapy (RT) can reduce dysphagia in patients with metastatic spinal cord compression (MSCC). Patient-reported outcome (PRO) is the only follow-up measure. Due to the fragile patient population, low respondent compliance was anticipated. We performed a planned interim analysis of dosimetry and respondent compliance, to ensure that the protocol requirements were met.

METHODS

Patients >18 years referred for cervical/thoracic MSCC radiotherapy in 1-10 fractions were included from two centres. Patients were randomized (1:1) to standard RT or oesophagus-sparing RT, where predefined oesophageal dose constraints were prioritized over target coverage. Patients completed a trial diary with daily reports of dysphagia for 5 weeks (PRO-CTC-AE) and weekly quality of life reports for 9 weeks (QLQ-C30, EQ-5D-5L). According to power calculation, 124 patients are needed for primary endpoint analysis. The sample size was inflated to 200 patients to account for the fragile patient population. The co-primary endpoints, peak patient-reported dysphagia, and preserved ability to walk (EQ-5D-5L), are analysed at 5 and 9 weeks, respectively. The interim analysis was conducted 90 days after the inclusion of patient no 100. Respondent compliance was assessed at 5 and 9 weeks. In all RT plans, oesophagus and target doses were evaluated regarding adherence to protocol constraints.

RESULTS

From May 2021 to November 2022, 100 patients were included. Fifty-two were randomized to oesophagus-sparing RT. In 23% of these plans, oesophagus constraints were violated. Overall, the dose to both target and oesophagus was significantly lower in the oesophagus-sparing plans. Only 51% and 41% of the patients were evaluable for co-primary endpoint analysis at five and nine weeks, respectively. Mortality and hospitalization rates were significantly larger in patients who completed <4 days PRO questionnaires.

CONCLUSION

Compliance was lower than anticipated and interventions to maintain study power are needed.

Robot and working tube-assisted invasion-controlled surgery for spinal metastases

Objective

This study aims to highlight the use of robots in surgery and that of tube-assisted minimally invasive surgery for spinal metastases, as well as elaborate on the concept of invasion-controlled surgery (ICS).

Summary of background

Many patients with spinal metastasis cancer cannot afford serious complications when undergoing traditional open surgery because of their poor physical condition. Robots and minimally invasive technology have been introduced into the field of spine surgery and they have shown significant advantages.

Methods

Six patients who underwent robot and working tube-assisted ICS for spinal metastases. Relevant demographic, medical, surgical, and postoperative data were collected from medical records and analyzed.

Results

Mean operative time was 3.8 h and the mean length of the surgical incision was 4.9 cm. The mean estimated blood loss was 400 ml. The mean bedtime and hospital length of stay were 3.2 days and 6.5 days, respectively. No obvious complications were reported during treatment. The mean accuracy of screw placement was 98%. The mean time for further system treatment after surgery was 5.8 days. All patients experienced significant pain relief. The mean preoperative visual analog scale (VAS) was 7.83 points. The mean VAS at 1 day, 1 week, and 1 month after surgery were 2.83, 1.83, and 1.17 points, respectively. Frankel grade was improved in five of six patients. One patient preoperatively with Frankel grade D was the same postoperatively.

Conclusion

The concept of ICS is suitable for patients with spinal metastases. Robot and working tube-assisted ICS for spinal metastases is one of the safest and most effective treatment methods.

Clinical Outcome and Histological Findings After Induced Leakage of PMMA Loaded With Methotrexate and Cisplatin During Vertebroplasty: Experimental Model in Pigs

STUDY DESIGN

Animal experimental model.

OBJECTIVE

To study the clinical behavior and histological changes in the spinal cord, nerve roots and perivertebral muscles of the spine after induced leakage of polymethylmethacrylate (PMMA) loaded with antiblastic drugs during vertebroplasty in an animal model of pigs.

METHODS

We performed vertebroplasty on 25 pigs. The animals were divided into 3 groups: vertebroplasty with PMMA alone (control group), vertebroplasty with PMMA loaded with methotrexate (MTX) and vertebroplasty with PMMA loaded with cisplatin (CYS). At 2 vertebral levels, epidural and prevertebral, massive cement leaks were induced. Animals were evaluated daily. Two weeks later, the pigs were sacrificed, and the tissues that came in contact with the cement were analyzed.

RESULTS

The clinical results for each of the groups were reported. The control group had no clinical alterations. In the MTX group, 2 pigs died before 1 week due to pneumonitis. In the CYS group, 4 animals had motor impairment, and 3 of the 4 had paraplegia. The histological results were as follows: the control and MTX groups showed synovial metaplasia, inflammatory reaction, crystal deposits, and giant cell reaction in the dura mater and muscle and all the animals in the CYS group had spinal cord and muscular necrosis.

CONCLUSIONS

Massive cement leak after vertebroplasty with PMMA loaded with cisplatin is extremely toxic to the spinal cord and muscles around the spine. Therefore, its use cannot be recommended for the treatment of vertebral metastases. Using PMMA loaded with methotrexate seems to be a safe procedure, but further research is needed.

Postoperative prolonged mechanical ventilation correlates to poor survival in patients with surgically treated spinal metastasis

Objective

Patients with spinal metastasis (SM) are at advanced stages of systemic cancer disease. Surgical therapy for SM is a common treatment modality enabling histopathological diagnosis and the prevention of severe neurological deficits. However, surgery for SM in this vulnerable patient cohort may require prolonged postoperative intensive care treatment, which could adversely affect the anticipated benefit of the surgery. We therefore assessed postoperative prolonged mechanical ventilation (PMV) as an indicator for intensive care treatment with regard to potential correlations with early postoperative mortality and overall survival (OS).

Methods

Between 2015 and 2019, 198 patients were surgically treated for SM at the author´s neurosurgical department. PMV was defined as postoperative mechanical ventilation of more than 24 hours. A multivariate analysis was performed to identify pre- and perioperative collectable predictors for 30 days mortality.

Results

Twenty out of 198 patients (10%) with SM suffered from postoperative PMV. Patients with PMV exhibited a median OS rate of 1 month compared to 12 months for patients without PMV (p < 0.0001). The 30 days mortality was 70% and after one year 100%. The multivariate analysis identified “PMV > 24 hrs” (p < 0.001, OR 0.3, 95% CI 0.02-0.4) as the only significant and independent predictor for 30 days mortality (Nagelkerke’s R2 0.38).

Conclusions

Our data indicate postoperative PMV to significantly correlate to high early postoperative mortality rates as well as to poor OS in patients with surgically treated SM. These findings might encourage the initiation of further multicenter studies to comprehensively investigate PMV as a so far underestimated negative prognostic factor in the course of surgical treatment for SM.

Prognostic factors for survival and ambulatory status at 8 weeks with metastatic spinal cord compression in the SCORAD randomised trial

BACKGROUND

Metastatic spinal cord compression (MSCC) carries a poor prognosis and management is based on the likelihood of maintaining mobility and predicted survival.

PATIENTS AND METHOD

SCORAD is a randomised trial of 686 patients comparing a single dose of 8 Gy radiotherapy with 20 Gy in 5 fractions. Data was split into a training set (412, 60%) and a validation set (274, 40%). A multivariable Cox regression for overall survival (OS) and a logistic regression for ambulatory status at 8 weeks were performed in the training set using baseline factors and a backward selection regression to identify a parsimonious model with p ≤ 0.10. Receiver Operating Characteristic (ROC) analysis evaluated model prognostic performance in the validation set. Validation of the final survival model was performed in a separate registry dataset (n = 348).

RESULTS

The survival Cox model identified male gender, lung, gastrointestinal, and other types of cancer, compression at C1-T12, presence of non-skeletal metastases and poor ambulatory status all significantly associated with worse OS (all p < 0.05). The ROC AUC for the selected model was 75% (95%CI: 69-81) in the SCORAD validation set and 68% (95%CI: 62-74) in the external validation registry data. The logistic model for ambulatory outcome identified primary tumour breast or prostate, ambulatory status grade 1 or 2, bladder function normal and prior chemotherapy all significantly associated with increased odds of ambulation at 8 weeks (all p < 0.05). The ROC AUC for the selected model was 72.3% (95% CI 62.6-82.0) in the validation set.

CONCLUSIONS

Primary breast or prostate cancer, and good ambulatory status at presentation, are favourable prognostic factors for both survival and ambulation after treatment.

Radiomics biopsy signature for predicting survival in patients with spinal bone metastases (SBMs)

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Prediction of survival is crucial for guiding patient-tailored treatment.

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Radiomics can be described as the next era of possibilities in precision medicine.

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Radiomics model had an inferior performance with no added predictive power to the clinical predictive model.

Study design

Retrospective analysis of a registered cohort of patients treated and irradiated for metastases in the spinal column in a single institute.

Objective

This is the first study to develop and internally validate radiomics features for predicting six-month survival probability for patients with spinal bone metastases (SBM).

Background data

Extracted radiomics features from routine clinical CT images can be used to identify textural and intensity-based features unperceivable to human observers and associate them with a patient survival probability or disease progression.

Methods

A study was conducted on 250 patients treated for metastases in the spinal column irradiated for the first time between 2014 and 2016, at the MAASTRO clinic in Maastricht, the Netherlands. The first 150 available patients were used to develop the model and the subsequent 100 patient were considered as a test set for the model. A bootstrap (B = 400) stepwise model selection, which combines both the forward and backward variable elimination procedure, was used to select the most useful predictive features from the training data based on the Akaike information criterion (AIC). The stepwise selection procedure was applied to the 400 bootstrap samples, and the results were plotted as a histogram to visualize how often each variable was selected. Only variables selected more than 90 % of the time over the bootstrap runs were used to build the final model.

A prognostic index (PI) called radiomics score (radscore) and clinical score (clinscore) was calculated for each patient. The prognostic index was not scaled, the original values were used which can be extracted from the model directly or calculated as a linear combination of the variables in the model multiplied by the respective beta value for each patient.

Results

The clinical model had a good discrimination power. The radiomics model, on the other hand, had an inferior performance with no added predictive power to the clinical model. The internal imaging characteristics do not seem to have a value in the prediction of survival. However, the Shape features were excluded from further analyses in our study since all biopsies had a standard shape hence no variability.

Predictors of Mortality in Patients with Advanced Cancer-A Systematic Review and Meta-Analysis

To timely initiate advance care planning in patients with advanced cancer, physicians should identify patients with limited life expectancy. We aimed to identify predictors of mortality. To identify the relevant literature, we searched Embase, MEDLINE, Cochrane Central, Web of Science, and PubMed databases between January 2000-April 2020. Identified studies were assessed on risk-of-bias with a modified QUIPS tool. The main outcomes were predictors and prediction models of mortality within a period of 3-24 months. We included predictors that were studied in ≥2 cancer types in a meta-analysis using a fixed or random-effects model and summarized the discriminative ability of models. We included 68 studies (ranging from 42 to 66,112 patients), of which 24 were low risk-of-bias, and 39 were included in the meta-analysis. Using a fixed-effects model, the predictors of mortality were: the surprise question, performance status, cognitive impairment, (sub)cutaneous metastases, body mass index, comorbidity, serum albumin, and hemoglobin. Using a random-effects model, predictors were: disease stage IV (hazard ratio [HR] 7.58; 95% confidence interval [CI] 4.00-14.36), lung cancer (HR 2.51; 95% CI 1.24-5.06), ECOG performance status 1+ (HR 2.03; 95% CI 1.44-2.86) and 2+ (HR 4.06; 95% CI 2.36-6.98), age (HR 1.20; 95% CI 1.05-1.38), male sex (HR 1.24; 95% CI 1.14-1.36), and Charlson comorbidity score 3+ (HR 1.60; 95% CI 1.11-2.32). Thirteen studies reported on prediction models consisting of different sets of predictors with mostly moderate discriminative ability. To conclude, we identified reasonably accurate non-tumor specific predictors of mortality. Those predictors could guide in developing a more accurate prediction model and in selecting patients for advance care planning.

Prognostic scores for survival as decisional support for surgery in spinal metastases: a performance assessment systematic review

PURPOSE

To review the evidence on the relative prognostic performance of the available prognostic scores for survival in spinal metastatic surgery in order to provide a recommendation for use in clinical practice.

METHODS

A systematic review of comparative external validation studies assessing the performance of prognostic scores for survival in independent cohorts was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Eligible studies were identified through Medline and Embase until May 2021. Studies were included when they compared at least four survival scoring systems in surgical or mixed cohorts across all primary tumor types. Predictive performance was assessed based on discrimination and calibration for 3-month, 1-year and overall survival, and generalizability was assessed based on the characteristics of the development cohort and external validation cohorts. Risk of bias and concern regarding applicability were assessed based on the 'Prediction model study Risk Of Bias Assessment Tool' (PROBAST).

RESULTS

Twelve studies fulfilled the inclusion criteria and covered 17 scoring systems across 5.130 patients. Several scores suffer from suboptimal development and validation. The SORG Nomogram, developed in a large surgical cohort, showed good discrimination on 3-month and 1-year survival, good calibration and was superior in direct comparison with low risk of bias and low concern regarding applicability. Machine learning algorithms are promising as they perform equally well in direct comparison. Tokuhashi, Tomita and other traditional risk scores showed suboptimal performance.

CONCLUSION

The SORG Nomogram and machine learning algorithms outline superior performance in survival prediction for surgery in spinal metastases. Further improvement by comparative validation in large multicenter, prospective cohorts can still be obtained. Given the heterogeneity of spinal metastases, superior methodology of development and validation is key in improving future machine learning systems.

An Overview of Decision Making in the Management of Metastatic Spinal Tumors

INTRODUCTION

Spinal metastases are the most commonly encountered spinal tumors. With increasing life expectancy and better systemic treatment options, the incidence of patients seeking treatment for spinal metastasis is rising. Radical resections and conventional low-dose radiotherapy have given way to modern 'separation' surgeries and stereotactic body radiotherapy which entails lesser morbidity and improved local control. This article provides an overview of the decision making and currently available treatment options for metastatic spinal tumors.

METHODS

A MEDLINE literature search was made for studies in English language reporting on human subjects, describing results of various treatment options that are a part of multidisciplinary management of metastatic spinal tumors. The highest-quality evidence available in the literature was reviewed.

DISCUSSION

Treatment of patients with metastatic spinal tumors is largely palliative, with radiotherapy and selective surgery being the mainstays of management. Multidisciplinary management that incorporates factors like patient performance status, expected survival and systemic burden of disease and employs well-validated decision-making frameworks for guiding treatment holds the key to an effective palliative treatment strategy. Effective pain management, achieving local control, adequate neurological decompression in the setting of epidural cord compression and surgical stabilization for mechanical stabilization are the main goals of treatment.

CONCLUSION

The management of metastatic spinal tumors has been rapidly evolving; currently, limited decompression and stabilization followed by postoperative SBRT for local tumor control are associated with less morbidity and may be referred to as the current standard of care in these patients.

Establishment and validation of nomogram model for survival predicting in patients with spinal metastases secondary to lung cancer

OBJECTIVES

To evaluate the prognostic effect of pre-treatment factors in patients with spinal metastases secondary to lung cancer, and establish a novel predicting nomogram for predicting the survival probability.

METHODS

A total of 209 patients operated for spinal metastases from lung cancer were consecutively enrolled, and divided into the training and validation samples with a ratio of 7:3, for model establishing and validating, respectively. Basing on the training sample, univariate and multivariate COX proportional hazard models were used for identifying the prognostic effect of pre-treatment factors, following which significant prognostic factors would be listed as items in nomogram to calculate the survival probabilities at 3, 6, 12 and 18 months. Then, the C-indexes and the calibration curves would be figured out to evaluate the discrimination ability and accuracy of the model both for the training and validation samples.

RESULTS

In the multivariate COX analysis, the gender, smoking history, location of spinal metastasis, visceral metastasis, Karnofsky performance status (KPS), adjuvant therapy, lymphocyte percentage and globulin were found to be significantly associated with the overall survival, and a novel nomogram was generated basing on these independent predictors. The C-indexes for the training and validation samples were 0.761 and 0.732, respectively. Favorable consistencies between the predicted and actual survival rates were demonstrated both in the internal and external validations.

DISCUSSION

Pre-treatment characteristics, including gender, smoking history, location of spinal metastasis, visceral metastasis, KPS, adjuvant therapy, percentage of lymphocyte, and serum globulin level, were identified to be significantly associated with overall survival of patients living with spinal metastases derived from lung cancer, and a user-friendly nomogram was established using these independent predictors.

A Novel Prediction Tool for Overall Survival of Patients Living with Spinal Metastatic Disease

OBJECTIVE

To identify the significant prognostic factors for overall survival in patients with spinal metastases and to establish an online widget for predicting survival with an interactive visual approach.

METHODS

Patients operated for spinal metastases between 2010 and 2018 were retrospectively enrolled and were randomly divided into training and validation samples with a ratio of 7:3. Patients' characteristics were analyzed with univariate and multivariate Cox analyses to identify independent prognostic factors basing on the training sample. A shiny web tool was developed by transforming the fitted multivariable Cox model into a visual interface. Time-dependent area under the curve plot and calibration curve were generated to assess the discrimination ability and consistency of the novel model, both for the training and validation samples.

RESULTS

A total of 265 consecutive patients were finally included, with 185 in the training sample and 80 in the validation sample. The primary tumor types, lesion site of metastasis, visceral metastasis, Frankel grade, operation category, number of surgical segments, and the preoperative percentage of lymphocyte were demonstrated to be significantly associated with overall survival. A novel shiny model (https://yang1209xg.shinyapps.io/predictspinalmetastasis/) that could provide predicted survival curve and median survival time was established, with favorable discrimination ability and consistency between predicted and actual survival both in internal and external data, according to time-dependent area under the curve plots and calibration curves.

CONCLUSIONS

A user-friendly shiny app with favorable discrimination ability and consistency was released online for predicting the survival of patients with spinal metastases. A continuous survival curve and the predicted median survival time are available to guide the treatment planning.

Multidisciplinary management of metastatic spine disease: initial symptom-directed management

In the past 2 decades, a deeper understanding of the cancer molecular signature has resulted in longer longevity of cancer patients, hence a greater population, who potentially can develop metastatic disease. Spine metastases (SM) occur in up to 70% of cancer patients. Familiarizing ourselves with the key aspects of initial symptom-directed management is important to provide SM patients with the best patient-specific options. We will review key components of initial symptoms assessment such as pain, neurological symptoms, and spine stability. Radiographic evaluation of SM and its role in management will be reviewed. Nonsurgical treatment options are also presented and discussed, including percutaneous procedures, radiation, radiosurgery, and spine stereotactic body radiotherapy. The efforts of a multidisciplinary team will continue to ensure the best patient care as the landscape of cancer is constantly changing.

Scoring Algorithms for Predicting Survival Prognosis in Patients With Metastatic Spinal Disease: The Current Status and Future Directions

Various survival scoring systems have been developed to help surgeons select the best candidates for appropriate therapies in patients with metastatic spinal disease. This study aims to discuss the current status and future directions of scoring systems for the prediction of survival prognosis in these patients. The search terms "spine metastases," "metastatic spinal disease," and "metastatic spinal cord compression" were combined with "survival prognosis," "scoring system," and "score" to elicit relevant literatures in PubMed and Embase databases. As a result, 159 articles were selected from PubMed, and 246 articles were extracted from Embase. After reviewing each article, we carefully included and analyzed 74 articles about the development and evaluation of scoring systems for predicting survival prognosis in spine metastases. In this review, those scoring systems were stratified into the historic scoring systems and the modern scoring systems on the basis of the proposed time. The historic scoring systems, including the original/revised Tokuhashi scoring system, the Bauer scoring system, the Tomita scoring system, and the Linden scoring system, and the modern scoring systems, such as the Lei scoring system, the Bartels scoring system, the Mizumoto scoring system, the Bollen scoring system, the Rades scoring system, Oswestry Spinal Risk Index, and the Choi risk calculator, were introduced and discussed in this review. Besides, the clinical effectiveness and pitfalls of the existing systems and the future directions of the next generation of scoring systems were also addressed and discussed. We recommended these scoring systems as preferable reference tools to help doctors to select surgical candidates. In patients with long-term life expectancy, radical surgery, such as wide or marginal excision, can be considered in patients with neurological deficits, spine instability, or severe back pain. Besides, with the advancement and improvement of medical technologies, surgical procedures are changing, which can affect surgical indications such as vertebroplasty, minimal invasive surgery, and percutaneous stabilization, which can also be used in patients with spine instability or severe back pain, and do not require much recovery; hence, they can even be used in patients with relative short-term life expectancy. However, the decision about the treatment of patients with metastatic spinal disease is so complicated and should never rely on prognostic scores alone. The final therapeutic decision should be made by interdisciplinary corporations of oncologists, radiologists, and spinal surgeons. Besides, individual intentions should be respected.

A Personalized Medicine Approach for the Management of Spinal Metastases with Cord Compression: Development of a Novel Clinical Prediction Model for Postoperative Survival and Quality of Life

Surgery should be considered for patients with metastatic epidural spinal cord compression (MESCC) with a life expectancy of ≥3 months. Given the heterogeneity of the clinical presentation and outcomes, clinical prognostic models (CPMs) can assist in tailoring a personalized medicine approach to optimize surgical decision-making. We aimed to develop and internally validate the first CPM of health-related quality of life (HRQoL) and a novel CPM to predict the survival of patients with MESCC treated surgically. Using data from 258 patients (AOSpine North America MESCC study and Nottingham MESCC registry), we created 1-year survival and HRQoL CPMs using a Cox model and logistic regression analysis with manual backward elimination. The outcome measure for HRQoL was the minimal clinical important difference in EuroQol 5-dimension questionnaire scores. Internal validation involved 200 bootstrap iterations, and calibration and discrimination were evaluated. Longer survival was associated with a higher SF-36 physical component score (hazard ratio [HR], 0.96). In contrast, primary tumor other than breast, thyroid, or prostate (unfavorable: HR, 2.57; other: HR, 1.20), organ metastasis (HR, 1.51), male sex (HR, 1.58), and preoperative radiotherapy (HR, 1.53) were not (c-statistic, 0.69; 95% confidence interval, 0.64-0.73). Karnofsky performance status <70% (odds ratio [OR], 2.50), living in North America (OR, 4.06), SF-36 physical component score (OR, 0.95) and SF-36 mental component score (OR, 0.96) were associated with the likelihood of achieving a minimal clinical important difference improvement in the EuroQol 5-Dimension Questionnaire score at 3 months (c-statistic, 0.74; 95% confidence interval, 0.68-0.79). The calibration for both CPMs was very good. We developed and internally validated the first CPMs of survival and HRQoL at 3 months postoperatively in patients with MESCC using the TRIPOD (transparent reporting of a multivariable prediction model for individual prognosis or diagnosis) guidelines. A web-based calculator is available (available at: http://spine-met.com) to assist with clinical decision-making.

Treatment Strategy for Metastatic Spinal Tumors: A Narrative Review

Metastatic spinal tumors are common, and their rising incidence can be attributed to the expanding aging population and increased survival rates among cancer patients. The decision-making process in the treatment of spinal metastasis requires a multidisciplinary approach that includes medical and radiation oncology, surgery, and rehabilitation. Various decision-making systems have been proposed in the literature in order to estimate survival and suggest appropriate treatment options for patients experiencing spinal metastasis. However, recent advances in treatment modalities for spinal metastasis, such as stereotactic radiosurgery and minimally invasive surgical techniques, have reshaped clinical practices concerning patients with spinal metastasis, making a demand for further improvements on current decision-making systems. In this review, recent improvements in treatment modalities and the evolution of decision-making systems for metastatic spinal tumors are discussed.

Survival prediction for oral tongue cancer patients via probabilistic genetic algorithm optimized neural network models

OBJECTIVES

High throughput pre-treatment imaging features may predict radiation treatment outcome and guide individualized treatment in radiotherapy (RT). Given relatively small patient sample (as compared with high dimensional imaging features), identifying potential prognostic imaging biomarkers is typically challenging. We aimed to develop robust machine learning methods for patient survival prediction using pre-treatment quantitative CT image features for a subgroup of head-and-neck cancer patients.

METHODS

Three neural network models, including back propagation (BP), Genetic Algorithm-Back Propagation (GA-BP), and Probabilistic Genetic Algorithm-Back Propagation (PGA-BP) neural networks were trained to simulate association between patient survival and radiomics data in radiotherapy. To evaluate the models, a subgroup of 59 head-and-neck patients with primary cancers in oral tongue area were utilized. Quantitative image features were extracted from planning CT images, a novel t-Distributed Stochastic Neighbor Embedding (t-SNE) method was used to remove irrelevant and redundant image features before fed into the network models. 80% patients were used to train the models, and remaining 20% were used for evaluation.

RESULTS

Of the three supervised machine-learning methods studied, PGA-BP yielded the best predictive performance. The reported actual patient survival interval of 30.5 ± 21.3 months, the predicted survival times were 47.3 ± 38.8, 38.5 ± 13.5 and 29.9 ± 15.3 months using the traditional PCA. Combining with the novel t-SNE dimensionality reduction algorithm, the predicted survival intervals are 35.8 ± 15.2, 32.3 ± 13.1 and 31.6 ± 15.8 months for the BP, GA-BP and PGA-BP neural network models, respectively.

CONCLUSION

The work demonstrated that the proposed probabilistic genetic algorithm optimized neural network models, integrating with the t-SNE dimensionality reduction algorithm, achieved accurate prediction of patient survival.

ADVANCES IN KNOWLEDGE

The proposed PGA-BP neural network, integrating with an advanced dimensionality reduction algorithm (t-SNE), improved patient survival prediction accuracy using pre-treatment quantitative CT image features of head-and-neck cancer patients.

Prognostic factors for overall survival in patients with spinal metastasis secondary to prostate cancer: a systematic review and meta-analysis

Background

To guide the selection of treatments for spinal metastases, the expected survival time is one of the most important determinants. Few scoring systems are fully applicable for spinal metastasis secondary to prostate cancer (PCa). This study aimed to identify the independent factors to predict the overall survival (OS) of patients with spinal metastases from PCa.

Methods

The PubMed, Embase and CENTRAL were retrieved by two reviewers independently, to identify studies analyzed the prognostic effect of different factors in spinal metastasis from PCa. A systematic review and quantitative meta-analysis was conducted with hazard ratio (HR) and 95% confidence interval (95%CI) as the effect size.

Results

A total of 12 retrospective cohort studies (1566 patients) were eligible for qualitative synthesis and 10 for quantitative meta-analyses. The OS was significantly influenced by performance status, visceral metastasis, ambulatory status and time from PCa diagnosis in more than half of the available studies. The meta-analyses demonstrated that OS was significantly influenced by visceral metastasis (HR = 2.24, 95%CI:1.53–3.27, p < 0.001), pre-treatment ambulatory status (HR = 2.64, 95%CI:1.82–3.83, p < 0.001), KPS (HR = 4.45, 95%CI:2.01–9.85, p < 0.001), ECOG (HR = 2.96, 95%CI:2.02–4.35, p < 0.001), extraspinal bone metastasis (HR = 2.04, 95%CI:1.13–3.68, p = 0.018), time developing motor deficit (HR = 1.57, 95%CI:1.30–1.88, p < 0.001) and time from PCa diagnosis (HR = 1.37, 95%CI:1.17–1.59, p < 0.001).

Conclusions

Visceral metastasis, ambulatory status, extraspinal bone metastasis, performance status, time developing motor deficit and time interval from primary tumor diagnosis were significantly associated with the OS for spinal metastasis from PCa. When selecting the treatment modality, clinicians should fully consider the patients’ systematic status based on all potential prognostic factors.

Level of evidence

I Meta-analysis.

Distribution and predictive value of initial presenting symptoms in spinal metastases from primary cancer patients

PURPOSE

Primary cancer patients may have some symptoms and develop spinal metastases in their disease progression. This study was to report the distribution and predictive value of specific initial presenting symptoms in patients with spine metastatic disease.

METHODS

The clinical information about patients with primary cancers was retrospectively collected and analyzed at their initial diagnosis from January 2008 to December 2017. The distribution and specific value of initial presenting symptoms were analyzed in predicting spinal metastases.

RESULTS

A total of 14,603 cancer patients were finally included, of whom 1665 (11.4%) cases were confirmed with spinal metastases. 41.55% (6067/14,603) patients had initial presenting symptoms, while 92.19% (1535/1665) patients with spinal metastases presented at least one initial presenting symptoms. Among 6269 patients with symptoms, 1535 (24.49%) were diagnosed with spinal metastases. Factors including primary tumor type, local pain, night-aggravating pain, limb numbness, limb weakness, unstable gait, claudication, loss of sphincter control, and weight loss are associated with the distribution of spinal metastases. The pooled sensitivity, specificity, positive predictive value, and negative predictive value were 90.9% (89.4-92.2%), 64.9% (64.0-65.7%), 24.99% (23.91-26.11%), and 98.23% (97.92-98.50%), respectively. Positive likelihood ratio of "night-aggravating pain" was 33.25 (12.65-87.36) and 17.26 (12.25-24.32) in patients < 45 and 45-64 years old, respectively.

CONCLUSIONS

The distribution of spinal metastases is associated with primary tumor type and initial presenting symptoms. The predictive value of initial presenting symptoms differs in age groups, but resembles in cancer types. The presence of night-aggravating pain had relative high value in predicting metastases in cancer patients under 65 years old.

Metastatic spinal cord compression

Metastatic spinal cord compression is compression of the spinal cord or cauda equina as a result of metastatic deposits in the spinal column. It affects approximately 4000 cases per year in England and Wales. Prompt identification and treatment of metastatic spinal cord compression is necessary to prevent irreversible neurological injury, treat pain and maintain patients' mobility, function and independence. Survival of patients with common malignancies has improved significantly with the ongoing development of radiotherapy and chemotherapy, as well as improved surgical treatment of resectable primary tumours. This article outlines the clinical approach to presentation, pathophysiology, diagnosis and management.

Surgical or Radiation Therapy for the Treatment of Cervical Spine Metastases: Results From the Epidemiology, Process, and Outcomes of Spine Oncology (EPOSO) Cohort

STUDY DESIGN

Ambispective cohort study design.

OBJECTIVES

Cervical spine metastases have distinct clinical considerations. The aim of this study was to determine the impact of surgical intervention (± radiotherapy) or radiotherapy alone on health-related quality of life (HRQOL) outcomes in patients treated for cervical metastatic spine tumours.

METHODS

Patients treated with surgery and/or radiotherapy for cervical spine metastases were identified from the Epidemiology, Process, and Outcomes of Spine Oncology (EPOSO) international multicentre prospective observational study. Demographic, diagnostic, treatment, and HRQOL (numerical rating scale [NRS] pain, EQ-5D (3L), SF-36v2, and SOSGOQ) measures were prospectively collected at baseline, 6 weeks, 3 months, and 6 months postintervention.

RESULTS

Fifty-five patients treated for cervical metastases were identified: 38 underwent surgery ± radiation and 17 received radiation alone. Surgically treated patients had higher mean spinal instability neoplastic scores compared with the radiation-alone group (13.0 vs 8.0, P < .001) and higher NRS pain scores and lower HRQOL scores compared to the radiation alone group (P < .05). From baseline to 6 months posttreatment, surgically treated patients demonstrated statistically significant improvements in NRS pain, EQ-5D (5L), and SOSGOQ2.0 scores compared with nonsignificant improvements in the radiotherapy alone group.

CONCLUSIONS

Surgically treated cervical metastases patients presented with higher levels of instability, worse baseline pain and HRQOL scores compared with patients who underwent radiotherapy alone. Significant improvements in pain and HRQOL were noted for those patients who received surgical intervention. Limited or no improvements were found in those treated with radiotherapy alone.

Epidemiological Characteristics of 1196 Patients with Spinal Metastases: A Retrospective Study

OBJECTIVES

To describe the epidemiological characteristics of patients with spinal metastases between 2007 and 2019.

METHODS

Patients with spinal metastases were identified from several clinical centers in China between January 2007 and July 2019. Demographics, primary tumor types, spinal involvement, and Clinical indicators of each patient were reviewed.

RESULTS

A total of 1196 patients were included in this study, 717 males (59.95%) and 479 females (40.05%), with a male to female ratio of 1.50:1. Most patients (63.71%) were in the ages range of 50 to 69 years. The mean age was 58.6 ± 11.6 (range 13-89) years and the median age was 59.0 years. The average age of females was younger than that of males, and the difference was statistically significant. The proportion of male patients over 60 years old was higher than that of females, and the difference was statistically significant. The most common primary tumor was lung cancer (n = 437, 36.54%), followed by unknown origin (n = 194, 16.22%), kidney cancer (n = 78, 6.52%), breast cancer (n = 76, 6.35%), and liver/biliary cancer (n = 75, 6.27%). The most common primary tumor was lung cancer in both males and females, followed by unknown origin in males and breast cancer in females. There were 730 patients (61.04%) in the subgroup of the number<3; the highest level was lumbar vertebrae, with 250 patients (34.25%). The remaining 466 patients (38.96%) were included in the subgroup of the number ≥ 3; the highest level was tumor metastasis of multiple-level of spine, with 334 patients (71.67%). Among the 1196 patients, spinal cord injury occurred in 54.01% of patients, 76.34% of patients developed moderate and above pain, 55.69% of patients had metastatic spinal cord compression, and only 26.67% of patients had a clear history of primary tumors.

CONCLUSION

This study provided a relatively detailed description of epidemiological characteristics in spinal metastases in China, which could assist orthopaedic surgeons to understand the clinical characteristics of spinal metastases, and is of great significance in guiding clinical diagnoses and scientific research.

Prognostic value of low psoas muscle mass in patients with cervical spine metastasis

Morphometric analyses have shown that the psoas muscle mass is associated with mortality in cancer patients. Because of the low incidence of cervical spine metastasis, few studies have been reported in this population. The present study aimed to identify the prognostic value of a psoas muscle mass in predicting overall survival. We also evaluated factors associated with surgical intervention for cervical spine metastases. We retrospectively evaluated 97 patients (mean age 65.2 years) diagnosed with cervical spine metastases between February 2009 and July 2016. The psoas muscle area was measured at the L3 level on computed tomography at the time nearest the diagnosis of cervical spine metastasis. Cox proportional hazards analyses were performed to evaluate the relation between overall survival and the psoas muscle's composition. The mean overall survival for patients who underwent surgery was not significantly different from that for those without surgery. Multivariate analyses showed that the lowest percentage quartile (0%-25%) of the psoas muscle mass was associated with poor overall survival after adjusting for age and the prognostic predictive value (hazard ratio 1.93, 95% confidence interval 1.12-3.32; p = 0.017). Spinal cord compression, spinal instability, palsy, and the poor prognostic predictive value were factors associated with surgical intervention. In conclusion, a psoas muscle mass in the lowest quartile was independently associated with shorter survival among patients with cervical spine metastases. Although the poor prognostic predictive value was associated with surgical treatment, the overall survival was not different between patients who did or did not undergo surgery.

Prognostic models for spinal metastatic disease: evolution of methodologies, limitations, and future opportunities

Advances in cancer biology and therapy have increased survival of metastatic disease patients and, in turn, the rates of metastatic epidural spinal cord compression (MESCC). Surgery can improve patient quality of life, but accurate estimation of postoperative survival is critical for appropriate patient selection, multidisciplinary management, and shared decision making. Survival estimation on the basis of clinician judgement alone has been shown to be inaccurate and unreliable. Numerous prognostic scoring systems have been developed to address this need but the inputs to these models, the modeling methodologies, and the model outputs have evolved significantly over time. Here we discuss the available scoring systems, existing limitations, and future opportunities.

Percutaneous transforaminal endoscopic decompression in the treatment of spinal metastases: A case report

RATIONALE

Spinal metastases are always associated with specific pain of back and limbs caused by nerve root compression. Although percutaneous endoscopic lumbar discectomy (PELD) has been widely performed on patients with back and radicular pain originating from lumbar disc herniation, this minimally invasive surgery is rarely used for the treatment of spinal metastases.

PATIENT CONCERNS

A 71-year-old woman with colon cancer and a known L3 vertebral body metastasis presented with significant progressive pain of low back and limbs.

DIAGNOSES

Magnetic resonance imaging (MRI) showed the L3 vertebral body had been involved by osteolytic vertebral metastasis, which extended into spinal canal and compressed the dural sac and nerve root.

INTERVENTIONS

The patient was treated with percutaneous transforaminal endoscopic decompression and palliative resection of metastases was performed twice on both sides, respectively. After the minimally invasive procedure, the decompression of the dural sac and nerve root was ideal.

OUTCOMES

No complications during the procedure were reported. The minimally invasive surgery resulted in prompt and permanent pain relief until the patient died 6 months later.

LESSONS

Percutaneous transforaminal endoscopic decompression could be an appropriate treatment option for the patients who suffer neurologic deficits that result from the spinal metastases.

Prognostic effect of factors involved in revised Tokuhashi score system for patients with spinal metastases: a systematic review and Meta-analysis

Background

Cancer patients’ survival time has obviously improved, with the development of systemic treatment techniques. However, the probability of metastases to the vertebrae has also been increased which makes some adverse effects on patients’ quality of life. The prediction of survival plays a key role in choosing therapeutic modality, and Tokuhashi Score was established as one of the most commonly used predictive systems for spinal metastases. Thus, this study was conducted to identify the prognostic effect of factors involved in revised Tokuhashi Score (RTS).

Methods

Two investigators independently retrieved relevant literature on platforms of PubMed, Embase and Cochrane Library. We identified eligible studies through title/abstract and full-text perusing. Data was extracted including general information of studies, participants’ characteristics, therapeutic modality, overall survival and prognostic effect of factors. Hazard ratio (HR) for each factor was synthesized if available through fixed- or random-effect models as appropriate.

Results

A total of 63 eligible studies with 10,411 participants were identified. Overall, cases with thyroid cancer had the highest survival rate, while the ones with non-small cell lung cancer and hepatocellular carcinoma lived for the shorted survival time. Performance status, bone metastasis, number of involved vertebrae, visceral metastasis, primary tumor and neurological status were regarded as significant predictors in 71.4, 40.0, 18.2, 63.4, 73.1 and 44.7% of the involved studies respectively. Thirty-eight articles were included in meta-analysis, and prognostic effects of five factors (apart from primary tumor) were analyzed. Factors were all proved to be significant except comparisons between KPS (Karnofsky Performance Status) 10–40 VS. 50–70 and single VS. multiple spinal metastases.

Conclusion

All factors of RTS were significant on prognosis predicting and should be considered when choosing therapeutic modality for spinal metastases. What’s more, we believe that more accurate prognosis may be obtained after removal of the cut-offs for KPS 10–40 VS. 50–70 and single VS. multiple involved vertebrae.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-5139-2) contains supplementary material, which is available to authorized users.

Clinical management of spinal metastases-The Dutch national guideline

This article is a summary of the revised Dutch multidisciplinary evidence-based guideline 'Spinal metastases' (English translation available at: https://www.oncoline.nl/spinal-metastases) that was published at the end of 2015. This summary provides an easy-to-use overview for physicians to use in their daily practice.

Prognostic Discrepancy on Overall Survival Between Ambulatory and Nonambulatory Patients with Metastatic Spinal Cord Compression

BACKGROUND

Contradictory results have been reported regarding the prognostic effect of ambulatory status in patients with metastatic spinal cord compression (MSCC). The aim of this study was to investigate whether ambulatory status is a significant predictor of overall survival in patients with MSCC and to distinguish the differences of predictors between patients who were ambulatory and those who were not ambulatory before operation.

METHODS

Three clinical centers were retrospectively reviewed to identify patients operated on for MSCC between 2005 and 2015. Fourteen prognostic factors were analyzed using Kaplan-Meier survival curves, univariate log-rank test, and multivariate Cox hazard regression model for the whole cohort and the subgroups of ambulatory and nonambulatory patients.

RESULTS

In all, 169 patients were consecutively enrolled. Their mean age was 59.6 ± 10.5 years (range, 18-84 years). The median survival time in the whole cohort was 7.0 ± 0.5 months, whereas it was 7.0 ± 0.8 months and 5.0 ± 1.3 months in ambulatory and nonambulatory patients, respectively. Multivariate Cox regression analysis showed that ambulatory status was not a significant predictor of overall survival (P = 0.266), but primary tumor type and Karnofsky performance status were independent predictors of overall survival for the whole cohort. Primary tumor and metastatic site were significantly associated with survival in ambulatory patients. Gender and Karnofsky performance status were associated with survival in nonambulatory patients.

CONCLUSIONS

Ambulatory status was not shown to predict the prognosis of patients with MSCC. prognostic factors should be distinguished between ambulatory and nonambulatory patients when choosing a therapeutic modality.

Management - spinal metastases

Due to a worldwide increase of cancer incidence and a longer life expectancy of patients with metastatic cancer, a rise in the incidence of symptomatic vertebral metastases has been observed. Metastatic spinal disease is one of the most dreaded complications of cancer as it is not only associated with severe pain, but also with paralysis, sensory loss, sexual dysfunction, urinary and fecal incontinency when the neurologic elements are compressed. Rapid diagnosis and treatment have been shown to improve both the quality and length of remaining life. This chapter on vertebral metastases with epidural disease and intramedullary spinal metastases will be discussed in terms of epidemiology, pathophysiology, demographics, clinical presentation, diagnosis, and management. With respect to treatment options, our review will summarize the evolution of conventional palliative radiation to modern stereotactic body radiotherapy for spinal metastases and the surgical evolution from traditional open procedures to minimally invasive spine surgery. Lastly, we will review the most common clinical prediction and decision rules, framework and algorithms, and guidelines that have been developed to guide treatment decision making.

Posterior decompression and occipitocervical fixation followed by intraoperative vertebroplasty for metastatic involvement of the axis

Background

Metastases to the upper cervical spine were rarely reported in the literature. However, metastases to this area may cause spinal instability and cord compression, which in turn can result in respiratory failure and neurological dysfunction. The present study investigated the efficacy and safety of posterior decompression and occipitocervical fixation followed by intraoperative vertebroplasty for this disease.

Methods

This was a retrospective study that included 10 patients with metastatic involvement of the axis from March 2002 to May 2014. All cases presented with occipitocervical pain: 5 patients with compressive myelopathy and 6 patients with radiculopathy. Japanese Orthopedic Association (JOA) scores and Visual Analogue Scale (VAS) were used to evaluate the improvement of neurological function and pain intensity, respectively.

Results

All patients underwent posterior decompression and occipitocervical fixation followed by intraoperative vertebroplasty. The VAS scores and JOA scores both improved postoperatively, from 8.2 ± 0.4 to 2.3 ± 0.2 and from 10.1 ± 2.2 to 14.2 ± 2.9, respectively. Additionally, the improvement rate of JOA was 52.4 ± 1.8%. The mean overall survival was 12.8 months. The median survival time was 7 months. The 6-month and 12-month survival rates were 70% and 40%, respectively. The mean duration of operation was 182 min and blood loss was 450 mL. The mean volume of bone cement injected was 4.0 mL. The cement extravasation was observed in only 1 patient without clinical symptoms. One patient developed tumour recurrence and died 1 month later.

Conclusions

Posterior decompression and occipitocervical fixation followed by intraoperative vertebroplasty was a safe and valuable palliative method with relatively less invasion to treat metastatic involvement of the axis.

Modern approaches to the management of metastatic epidural spinal cord compression

Metastatic epidural spinal cord compression (MESCC) is an oncologic emergency requiring prompt treatment to maximize neurologic function, ambulatory function and local control. Traditionally, options for MESCC included external beam radiation therapy with or without surgery. Surgery has usually been reserved for the patient with optimal performance status, single level MESCC or mechanical instability. Advances in external beam radiation therapy such as the development of stereotactic body radiation therapy have allowed for the delivery of high-dose radiation, allowing for both long-term pain and local control. Surgical advances, such as separation surgery, minimal access spine surgery and percutaneous instrumentation, have decreased surgical morbidity. This review summarizes the latest advances and evidence in MESCC to enable modern management.

Symptomatic spinal metastasis: A systematic literature review of the preoperative prognostic factors for survival, neurological, functional and quality of life in surgically treated patients and methodological recommendations for prognostic studies

Purpose

While several clinical prediction rules (CPRs) of survival exist for patients with symptomatic spinal metastasis (SSM), these have variable prognostic ability and there is no recognized CPR for health related quality of life (HRQoL). We undertook a critical appraisal of the literature to identify key preoperative prognostic factors of clinical outcomes in patients with SSM who were treated surgically. The results of this study could be used to modify existing or develop new CPRs.

Methods

Seven electronic databases were searched (1990–2015), without language restriction, to identify studies that performed multivariate analysis of preoperative predictors of survival, neurological, functional and HRQoL outcomes in surgical patients with SSM. Individual studies were assessed for class of evidence. The strength of the overall body of evidence was evaluated using GRADE for each predictor.

Results

Among 4,818 unique citations, 17 were included; all were in English, rated Class III and focused on survival, revealing a total of 46 predictors. The strength of the overall body of evidence was very low for 39 and low for 7 predictors. Due to considerable heterogeneity in patient samples and prognostic factors investigated as well as several methodological issues, our results had a moderately high risk of bias and were difficult to interpret.

Conclusions

The quality of evidence for predictors of survival was, at best, low. We failed to identify studies that evaluated preoperative prognostic factors for neurological, functional, or HRQoL outcomes in surgical patients with SSM. We formulated methodological recommendations for prognostic studies to promote acquiring high-quality evidence to better estimate predictor effect sizes to improve patient education, surgical decision-making and development of CPRs.

Quality of life after different surgical procedures for the treatment of spinal metastases: results of a single-center prospective case series

OBJECTIVE

The performance of surgery for spinal metastases is rapidly increasing. Different surgical procedures, ranging from stabilization alone to stabilization combined with corpectomy, are thereby performed for various indications. Little is known about the impact of these different procedures on patient quality of life (QOL), but this factor is crucial when discussing the various therapeutic options with patients and their families. Thus, the authors of this study investigated the effect of various surgical procedures for spinal metastases on patient QOL.

METHODS

The authors prospectively followed a cohort of 113 patients with spinal metastases who were referred to their clinic for surgical evaluation between July 2012 and July 2014. Quality of life was assessed using the EQ-5D at intake and at 3, 6, 9, and 12 months after treatment.

RESULTS

Nineteen patients were treated conservatively, 41 underwent decompressive surgery with or without stabilization, 47 underwent a piecemeal corpectomy procedure with stabilization and expandable cage reconstruction, and 6 had a stabilization procedure without decompression. Among all surgical patients, the mean EQ-5D score was significantly increased from 0.44 pretreatment to 0.59 at 3 months after treatment (p < 0.001). Mean EQ-5D scores at 1 year after surgery further increased to 0.84 following decompression with stabilization, 0.74 after corpectomy with stabilization, and 0.94 after stabilization without decompression. Frankel scores also improved after surgery. There were no significant differences in improvements in EQ-5D scores and Frankel grades among the different surgical procedures. In addition, mortality and complication rates were similar.

CONCLUSIONS

Quality of life can improve significantly after various extensive and less extensive surgical procedures in patients with spinal metastases. The relatively invasive corpectomy procedure, as compared with alternative less invasive techniques, does not negatively affect outcome.

The Effect of Perioperative Radiation Therapy on Spinal Bone Fusion Following Spine Tumor Surgery

Introduction

Perioperative irradiation is often combined with spine tumor surgery. Radiation is known to be detrimental to healing process of bone fusion. We tried to investigate bone fusion rate in spine tumor surgery cases with perioperative radiation therapy (RT) and to analyze significant factors affecting successful bone fusion.

Methods

Study cohort was 33 patients who underwent spinal tumor resection and bone graft surgery combined with perioperative RT. Their medical records and radiological data were analyzed retrospectively. The analyzed factors were surgical approach, location of bone graft (anterior vs. posterior), kind of graft (autologous graft vs. allograft), timing of RT (preoperative vs. postoperative), interval of RT from operation in cases of postoperative RT (within 1 month vs. after 1 month) radiation dose (above 38 Gy vs. below 38 Gy) and type of radiation therapy (conventional RT vs. stereotactic radiosurgery). The bone fusion was determined on computed tomography images.

Result

Bone fusion was identified in 19 cases (57%). The only significant factors to affect bony fusion was the kind of graft (75% in autograft vs. 41 in allograft, p=0.049). Other factors proved to be insignificant relating to postoperative bone fusion. Regarding time interval of RT and operation in cases of postoperative RT, the time interval was not significant (p=0.101).

Conclusion

Spinal fusion surgery which was combined with perioperative RT showed relatively low bone fusion rate (57%). For successful bone fusion, the selection of bone graft was the most important.

Prediction of Quality of Life and Survival After Surgery for Symptomatic Spinal Metastases: A Multicenter Cohort Study to Determine Suitability for Surgical Treatment

BACKGROUND

Surgery for symptomatic spinal metastases aims to improve quality of life, pain, function, and stability. Complications in the postoperative period are not uncommon; therefore, it is important to select appropriate patients who are likely to benefit the greatest from surgery. Previous studies have focused on predicting survival rather than quality of life after surgery.

OBJECTIVE

To determine preoperative patient characteristics that predict postoperative quality of life and survival in patients who undergo surgery for spinal metastases.

METHODS

In a prospective cohort study of 922 patients with spinal metastases who underwent surgery, we performed preoperative and postoperative assessment of EuroQol EQ-5D quality of life, visual analog score for pain, Karnofsky physical functioning score, complication rates, and survival.

RESULTS

The primary tumor type, number of spinal metastases, and presence of visceral metastases were independent predictors of survival. Predictors of quality of life after surgery included preoperative EQ-5D (P = .002), Frankel score (P < .001), and Karnofsky Performance Status (P < .001).

CONCLUSION

Data from the largest prospective surgical series of patients with symptomatic spinal metastases revealed that tumor type, the number of spinal metastases, and the presence of visceral metastases are the most useful predictors of survival and that quality of life is best predicted by preoperative Karnofsky, Frankel, and EQ-5D scores. The Karnofsky score predicts quality of life and survival and is easy to determine at the bedside, unlike the EQ-5D index. Karnofsky score, tumor type, and spinal and visceral metastases should be considered the 4 most important prognostic variables that influence patient management.

Prediction of survival prognosis after surgery in patients with symptomatic metastatic spinal cord compression from non-small cell lung cancer

Background

The aim of this study was to develop a scoring system for prediction of survival prognosis after surgery in patients with symptomatic metastatic spinal cord compression (MSCC) from non-small cell lung cancer (NSCLC).

Methods

We retrospectively analyzed nine preoperative characteristics for survival in a series of 64 patients with NSCLC who were operated with posterior decompression and spine stabilization for MSCC. Characteristics significantly associated with survival on multivariate analysis were included in the scoring system. The scoring point for each significant characteristic was derived from the hazard ratios on Cox proportional hazards model. The total score for each patient was obtained by adding the scoring points of all significant characteristics.

Results

Eastern Cooperative Oncology Group (ECOG) performance status, number of involved vertebrae, visceral metastases, and time developing motor deficits had significant impact on survival on multivariate analysis and were included in the scoring system. According to the prognostic scores, which ranged from 4 to 10 points, three prognostic groups were designed: 4–5 points (n = 22), 6–7 points (n = 23), and 8–10 points (n = 19). The corresponding 6-month survival rates were 95, 47 and 11 %, respectively (P < 0.0001). In addition, the functional outcome was worse in the group of patients with 8–10 points compared with other two prognostic groups.

Conclusions

The new scoring system will enable physicians to identify patient with MSCC from NSCLC who may be a candidate for decompression and spine stabilization, more radical surgery, or supportive care alone. Patients with scores of 4–5, who have the most favorable survival prognosis and functional outcome, can be treated with more radical surgery in order to realize better local control of disease and prevent the occurrence of local disease. Patients with scores of 6–7 points should be surgical candidates, because survival prognosis and functional outcome are acceptable after surgery, while patients with scores of 8–10 points, who have the shortest survival time and poorest functional outcome after surgery, appear to be best treated with radiotherapy or best supportive care.

Palliative surgery for cervical spine metastasis

INTRODUCTION

The present study aimed to assess the immediate/early clinical outcomes and surgical results of 11 consecutive patients who underwent palliative cervical spine surgery for symptomatic spinal metastases.

METHODS

This single-surgeon retrospective case series analysed 12 surgical procedures that were performed for symptomatic cervical spinal metastasis in 11 consecutive patients. All surgeries were carried out at Singapore General Hospital, Singapore, from 2007 to 2013. Preoperative medical oncological assessment/staging was performed on each patient--all patients presented with either axial neck pain or neurological deficits, and had no bladder or bowel symptoms. The primary outcomes analysed were postoperative neurological power and improvement in neck pain.

RESULTS

Anterior (n = 5), posterior (n = 4) and combined (n = 2) surgical approaches were used for decompression and stabilisation. Comparing between pre- and postoperative pain scores (scored according to the visual analog scale), and pre- and postoperative limb power scores (scored according to the Medical Research Council scale for muscle strength), we found that all patients showed improvement in their symptoms. Postoperatively, patients had either improvement or preservation of neurological power, and all patients had a decrease in axial neck pain after surgery. Although there was one case of minor pedicle screw instrumentation malplacement, this did not result in any neurological symptoms. Median survival for the patients was 108 (range 7‒1,095) days.

CONCLUSION

Palliative surgery for cervical spine metastasis is safe with good neurological results, low complication rates, and improvement in neck pain. A multidisciplinary approach involving surgeons, medical oncologists and radiotherapists is needed to optimise patient care and outcome.

Prediction of life expectancy in patients with spinal epidural metastasis

BACKGROUND

The treatment of spinal epidural metastasis is multidisciplinary and usually involves a team of medical oncologists, radiologists, radiotherapists, and spinal surgeons. Life expectancy is one of the factors considered when deciding whether surgery is warranted. Because expert estimates of life expectancy are generally not reliable, a prediction model is needed. Here, we temporally validated a model that was previously validated geographically.

METHODS

The records of 110 consecutive patients who were referred with a spinal epidural metastasis were collected prospectively from 2009 to 2013 in order to validate the model, which was published in 2011. The actual and estimated life expectancies were represented graphically, and calibration and discrimination were determined. The calibration slope, Harrell's c-index, D, and R2D were calculated. Hazard ratios in the derivation set of 2011 were compared with the validation set. Misspecification was determined using the joint test for β*.

RESULTS

The calibration slope was 0.64 ± 0.15 (95% CI: 0.34-0.94), Harrell's c-index was 0.72, D was 1.08, and R2D was 0.22, indicating slightly worse discrimination in the derivation set. The joint test for β* = 0 was statistically significant and indicated misspecification; however, this misspecification was attributed entirely to the surgical group.

CONCLUSIONS

We validated a prediction model for surgical decision making, showing that the model's overall performance is good. Based on these results, this model will help clinicians to decide whether to offer surgery to patients with spinal epidural metastasis.

Improved patient selection by stratified surgical intervention: Aarhus Spinal Metastases Algorithm

BACKGROUND CONTEXT

Choosing the best surgical treatment for patients with spinal metastases remains a significant challenge for spine surgeons. There is currently no gold standard for surgical treatments. The Aarhus Spinal Metastases Algorithm (ASMA) was established to help surgeons choose the most appropriate surgical intervention for patients with spinal metastases.

PURPOSE

The purpose of this study was to evaluate the clinical outcome of stratified surgical interventions based on the ASMA, which combines life expectancy and the anatomical classification of patients with spinal metastases to inform surgical decision making.

STUDY DESIGN/SETTING

This is a retrospective study based on a prospective database.

PATIENT SAMPLE

A consecutive series of 515 spinal metastatic patients who underwent surgically treatment from December 1992 to June 2012 in Aarhus University Hospital were included prospectively and analyzed in detail retrospectively.

OUTCOME MEASURES

Survival time after surgery was determined for all patients. Neurological function was assessed using the Frankel score preoperatively and postoperatively (at the time of discharge). Complete outcome data were retrieved in 97.5% of this cohort.

METHODS

Patients with spinal metastases were identified from an institutional database that prospectively collected data since 1992. Survival status data were obtained from a national registry. Neurological function was determined from the same institutional database or local Electronic Patient Journal system. Surgeons evaluated and classified patients into five surgical groups preoperatively by using the revised Tokuhashi score (TS) and the Tomita anatomical classification (TC).

RESULTS

The overall median survival time of the cohort was 6.8 (95% confidence interval: 6.1-7.9) months. The median survival times in the five surgical groups determined by the ASMA were 2.1 (TS 0-4, TC 1-7), 5.1 (TS 5-8, TC 1-7), 12.1 (TS 9-11, TC 1-7 or TS 12-15, TC 7), 26.0 (TS 12-15, TC 4-6), and 36.0 (TS 12-15, TC 1-3) months. The 30-day mortality rate was 7.5%. Postoperative neurological function was maintained or improved in 469 patients (92.3%). Overall reoperation rate was 13.5%, commonly because of postoperative hematoma and new limb weakness.

CONCLUSIONS

The ASMA recommends at least two surgical options for a particular patient by determining the preoperative life expectancy and anatomical classification of the spinal metastases. This algorithm could help spine surgeons to discriminate the risks of surgeries. The ASMA provides a tool to guild surgeons to evaluate the spinal metastases patients, select potential optimal surgery, and avoid life-threatening risks.

Minimally invasive option using percutaneous pedicle screw for instability of metastasis involving thoracolumbar and lumbar spine : a case series in a single center

Objective

To report a minimally invasive treatment option using percutaneous pedicle screw fixation with adjuvant treatment for metastatic thoraco-lumbar and lumbar spinal tumors.

Methods

This is a retrospective study of charts of patients with spinal metastases. All were older than 18 years of age and were considered to have more than 3 months of life expectancy. The patients had single or two level lesions, and compression fracture or impending fracture. Exclusion criterion was metastasis showing severe epidural compression with definite neurological symptoms. Usually spinal segments from one level above to below pathology were stabilized. Visual analog scale (VAS) score for pain assessment and Frankel scale for neurological deficit were used, while pre- and post-operative performance status was evaluated using the Eastern Cooperative Oncology Group (ECOG).

Results

Twelve patients (nine men, three women; median age 54.29 years) underwent surgery. All patients presented with back pain with/without radicular pain. There were no early complications and perioperative mortalities. Following surgery, a significant difference between average pre- and post-operative VAS scores was found (p=0.003). Overall, 91.8% of patients (11/12) experienced improvement in their ECOG score post-operatively. The mean ambulation time was 196.9 days [95% confidence interval (CI), 86.2-307.6 days; median, 97 days]. During follow-up, nine patients died and the mean overall survival time in enrolled twelve patients was 249.9 days (95% CI, 145.3-354.4 days; median, 176 days).

Conclusion

Minimally invasive treatment using percutaneous pedicle screw fixation with adjuvant treatment is a good alternative treatment option for potential instability of the thoraco-lumbar and lumbar spinal metastasis.

Prognostic parameters and spinal metastases: a research study

OBJECT

To identify pre-operative prognostic parameters for survival in patients with spinal epidural neoplastic metastasis when the primary tumour is unknown.

METHODS

This study was a retrospective chart review of patients who underwent surgery for spinal epidural neoplastic metastases between February 1997 and January 2011. The inclusion criteria were as follows: known post-operative survival period, a Karnofsky Performance Score equal to or greater than 30 points and a post-operative neoplastic metastasis histological type. The Kaplan-Meier method was used to estimate post-operative survival, and the Log-Rank test was used for statistical inference.

RESULTS

A total of 52 patients who underwent 52 surgical procedures were identified. The mean age at the time of spinal surgery was 53.92 years (std. deviation, 19.09). The median survival after surgery was 70 days (95% CI 49.97-90.02), and post-operative mortality occurred within 6 months in 38 (73.07%) patients. Lung cancer, prostate cancer, myeloma and lymphoma, the 4 most common primary tumour types, affected 32 (61.53%) patients. The three identified prognostic parameters were the following: pre-operative walking incapacity (American Spinal Injury Association, A and B), present in 86.53% of the patients (p-value = 0.107); special care dependency (Karnofsky Performance Score, 10-40 points), present in 90.38% of the patients (p-value = 0.322); and vertebral epidural neoplastic metastases that were in contact with the thecal sac (Weinstein-Boriani-Biagini, sector D), present in 94.23% of the patients (p-value = 0.643). When the three secondary prognostic parameters were combined, the mean post-operative survival was 45 days; when at least one was present, the survival was 82 days (p-value = 0.175).

CONCLUSIONS

Walking incapacity, special care dependency and contact between the neoplastic metastases and the thecal sac can help determine the ultimate survival of this patient population and, potentially, which patients would benefit from surgery versus palliation alone. A 2- to 3-month post-operative survival period justified surgical treatment.

Reconstruction with expandable cages after single- and multilevel corpectomies for spinal metastases: a prospective case series of 60 patients

BACKGROUND CONTEXT

Expandable cages are widely used to reconstruct the spine after the removal of vertebral metastases. Long-term results, however, are lacking, and there is little information on reconstruction after multilevel corpectomies.

PURPOSE

To determine long-term outcome for reconstruction of the spine with expandable cages after single and multilevel corpectomies for spinal metastases.

STUDY DESIGN

A prospective cohort study of 60 consecutive patients with spinal metastases treated with expandable cages.

METHODS

All patients were prospectively followed with regular clinical and radiographic evaluation. Outcome measures were the Frankel score, patients' self-reported recovery, radiological alignment of the spine, and neurologic plus biomechanical complications.

RESULTS

Sixty patients were treated with expandable cages in our hospital in a 5-year period with a maximum follow-up of 6 years. Single-level reconstruction was performed in 48 cases, 2-level in 8, and 3-level in 4. Postoperatively, the Frankel score had improved significantly (p=.03), the segment height had increased (p=.02), and, in severe cases of kyphosis (>20°), the regional angulation had been corrected compared with preoperatively (p<.001). Complication rate, however, was high (36.7%), in particular after multilevel reconstruction, in which three cases had to be reoperated years after the initial surgery; reasons for this were hardware failure, progressive kyphosis, and bronchial perforation. Good recovery was reported in 70% of all patients.

CONCLUSIONS

Expandable cages can be used successfully in reconstruction of the spine after single and multilevel corpectomies for spinal metastases. However, long-term complication rate is high. Promotion of bony fusion, prevention of soft-tissue damage, adequate posterior stabilization, and careful patient selection may reduce these complications.