Surgical indications and prognosis in spinal metastases

Comparing prognostic factors in patients with spinal metastases: a literature review

For cancer patients with spinal metastases, palliative treatments are directed toward improving the patient's symptoms and quality of life. The expected prognosis of patients plays a large role in guiding treatment decisions, particularly when deciding between surgical management and conservative treatments, such as radiotherapy. This study aims to review the factors that can accurately predict the survival of patients with spinal metastases. The authors conducted a literature search on studies identifying prognostic factors using PubMed (1966–2011), Ovid MEDLINE (1948 to July 2011) and EMBASE (1947–2011) databases. Articles in English were included if they conducted retrospective or prospective analyses on predictors of survival for patients with spinal metastases; articles validating or examining the accuracy of existing scoring systems using prognostic factors were also included. A total of 29 studies were identified. A general consensus of the literature was found with respect to three prognostic factors: the patient's primary cancer site, the extent of the metastases and the general condition or performance score. Further research is recommended to assess the prognostic value of other factors identified by several studies, including age, neurological deficit and previous treatments. For future studies, the authors encourage the development of models capable of inclusion of all patients with spinal metastases.

Primary Extradural Epithelioid Leiomyosarcoma of the Cervical Spine: Case Report and Literature Review

OBJECTIVE AND IMPORTANCE:

No case of primary epithelioid leiomyosarcoma involving the spine has been reported previously.

CLINICAL PRESENTATION:

A 61-year-old Nigerian woman presented with progressive spastic quadriparesis and acute urinary retention. Her only medical history included a total abdominal hysterectomy for fibroids 10 years earlier in Nigeria. Results of the general examination were normal. Pyramidal spastic quadriparesis (3/5) with a sensory level at C5–C6 was found neurologically. Magnetic resonance imaging scans of the brain and spine revealed extradural cord compression at C3–C5 as the sole abnormality. This was caused by a large, soft tissue mass arising from the erector spinae muscles, which was predominantly isointense on T1-weighted images, of mixed intensity on T2-weighted images, and homogenously enhanced after gadolinium contrast agent administration. There was an associated signal change in the cord at C3–C4. Computed tomography confirmed the predominantly soft tissue involvement, but with bone erosion and infiltration within the posterior elements of C4. Systemic screening for cancer was negative.

INTERVENTION:

At decompressive laminectomy, urgently undertaken under corticosteroid cover, an excessively vascularized, soft tissue tumor was subtotally excised, after which independent walking and normal sphincter function were regained within 1 week. Four weeks later, a complete macroscopic tumor excision was undertaken, incorporating lateral mass (C3–C6) and C2 pedicle screw stabilization, along with iliac crest bone grafting. The patient's neurological status continued to improve. However, while awaiting radical radiotherapy, the patient declined further treatment and returned to her native Nigeria. Histopathological findings were consistent with an epithelioid leiomyosarcoma.

CONCLUSION:

This is the first reported case of a primary craniospinal epithelioid leiomyosarcoma.

Primary osteosarcoma of the thoracic spine: report of an unusual elderly patient with autopsy findings

STUDY DESIGN

A case report of primary osteosarcoma of the spine in an elderly patient.

OBJECTIVE

The histopathological features of osteosarcoma vary widely, often leading to diagnostic difficulties particularly when there is little evidence of osteoid formation. The report describes the difficulty in the diagnosis of osteosarcoma of the thoracic vertebra.

SETTING

Department of Orthopaedics and Rehabilitation Medicine, Fukui University Faculty of Medicine, Fukui, Japan.

METHOD

A 78-year-old man presented with paraparesis and underwent urgent anterior excision of a primary spinal tumor emanating from the T10 vertebra followed by artificial vertebral replacement. The patient eventually died of disseminated disease of vertebral osteosarcoma.

RESULTS

Samples from the T10 vertebral tumor showed neoplastic growth of atypical spindle-shaped cells, with foci of storiform-like proliferation. The tissue also demonstrated positive immunohistochemical staining for vimentin and alpha-smooth muscle actin and a tentative diagnosis of leiomyosarcoma was made. However, a metastatic nodule of the chest wall at autopsy showed focal osteoid formation, a finding not seen in the primary tumor.

CONCLUSION

Early detection and accurate diagnosis is important for improving not only patient prognosis but also the quality of life. We should always consider this rare entity, particularly in elderly patients who present with back pain and vertebral collapse.

Paraparesis due to spinal leiomyosarcoma lesion in the thoracic spine accompanied by two leiomyosarcoma lesions in the back and the thigh over an interval of 4 years

We present an 83-year-old man who developed three different leiomyosarcoma lesions in the thigh, back, and thoracic spine. The pathology of the thigh tumour was pleomorphic leiomyosarcoma. MRI after 4 years showed a vertebral bone lesion associated with spinal cord compression at T7 and a paravertebral mass lesion at T9-T10. Surgical treatment for the spinal lesion which caused paraparesis improved the neurological symptoms. The pathological features of the lesions in the back and spine were identical and rather distinct from those of the previous thigh lesion. Spinal leiomyosarcoma causing paraparesis and the two other with soft-tissue leiomyosarcoma lesions with different pathological features in a single patient over a period of 4 years is an extremely rare occurrence.

Spinal manifestation of metastasizing leiomyosarcoma

STUDY DESIGN

Case report.

OBJECTIVE

To provide additional information on possible relations between uterine and spinal manifestations of leiomyosarcoma.

SUMMARY OF BACKGROUND DATA

Spinal metastases and primary spinal manifestation of leiomyosarcoma and other malignant smooth muscle tumors are rarely observed.

METHODS

Clinical and radiologic follow-up of a patient with a spinal tumor.

RESULTS

A 46-year-old women had rapidly progressive paraplegia caused by an extramedullary lesion in the extradural space at T2-T3, with spinal cord compression. After surgical decompression, the resected tumor was histologically classified as a leiomyosarcoma. Diagnostic work-up failed to detect the primary tumor site. Previous medical history had been uneventful except for hysterectomy 3 years earlier for a leiomyoma. Extended necroses and focal metaplasia were already described in the hysterectomy specimen indicating malignant disease; however, it was not definitely diagnosed. Multiple leiomyosarcoma metastases developed 22 months later.

CONCLUSIONS

In retrospect, the origin of the leiomyosarcoma that manifested in the thoracic spine of the patient must be reconsidered. Rather than a primary dural leiomyosarcoma, this tumor represented the first evidence of recurrence of a missed diagnosis of early-stage uterine leiomyosarcoma.