Recurrent epithelioid sarcoma in the thoracic spine successfully treated with multilevel total en bloc spondylectomy

Epithelioid Sarcoma of the Spine: A Review of Literature and Case Report

Epithelioid sarcoma is a rare malignant mesenchymal tumor that represents less than 1% of soft-tissue sarcomas. Despite its slow growth, the overall prognosis is poor with a high rate of local recurrence, lymph-node spread, and hematogenous metastasis. Primary epithelioid sarcoma arising from the spine is extremely rare, with limited data in the literature. We review the existing literature regarding spinal epithelioid sarcoma and report a case of epithelioid sarcoma arising from the spinal cord. A 54 year old male presented with a 1-month history of progressive left upper-limb weakness and numbness. Magnetic resonance imaging (MRI) of the spine showed an enhancing intramedullary mass at the level of T1 also involving the left T1 nerve root. Systemic radiological examination revealed no other lesion at presentation. Surgical excision of the mass was performed, and histology was consistent with epithelioid sarcoma of the spine. Despite adjuvant radiotherapy, there was aggressive local recurrence and development of intracranial metastatic spread. The patient died of the disease within 5 months from presentation. To the best of our knowledge, spinal epithelioid sarcoma arising from the spinal cord has not yet been reported. We review the challenges in diagnosis, surgical treatment, and oncologic outcome of this case.

Systematic Review of Published Cases of Primary Epithelioid Sarcoma of the Spine

BACKGROUND Epithelioid sarcoma is rare, represents less than 1% of all sarcomas, usually occurs in the extremities, and rarely presents as a primary sarcoma of the spine. Publications are usually single reports or case series. We aimed to undertake a systematic review of publications of cases of primary epithelioid sarcoma of the spine to evaluate clinical presentation, diagnosis, management, and patient outcomes. MATERIAL AND METHODS We searched studies on spinal epithelioid sarcoma in the PubMed database. Only studies with secondary epithelioid sarcoma or without effective data for analysis were excluded. Cases in which epithelioid sarcoma first invaded other sites and then affected the spine were also excluded. RESULTS Twenty-three patients from 13 studies were included in the study, aged between 14 and 65 years, and the sex ratio of female to male was 1: 2.29. The survival time was 18.7±13.8 months. The survival time of males was longer than that of females (22.9±14.4 vs 9.0±4.6, P=0.027). The onset age was linearly correlated with the size of the lesion (size=-0.161*age+11.841).The lesions located in lumbar vertebra had the worst prognosis. Postoperative radiotherapy had a statistically significant effect on survival time (P=0.040). CONCLUSIONS This systematic review identified 23 published cases of primary epithelioid sarcoma of the spine. Pain was the main presenting symptom, and tumor size increased with patient age. Female sex and primary location in the lumbar spine were associated with poor survival. Although surgery was the first-line treatment, postoperative radiotherapy and chemotherapy may improve clinical outcomes.

Epithelioid Sarcoma of Lumbar Spine: A Rare Mesenchymal Tumor Masquerading as Infection

Epithelioid sarcoma of the spine has been rarely reported in the literature. Its diagnosis is challenging due to nonspecific findings. We report a case of 42-year-old gentleman with back pain. Magnetic resonance imaging (MRI) revealed lesion in the L4 vertebral body extending into the spinal canal with pre and paravertebral involvement. He underwent posterior spinal decompression and instrumentation with biopsy. Histopathological examination was nonspecific. Considering clinical and radiological features, antitubercular treatment was initiated. The patient developed acute onset weakness of both lower extremities 1 month post-surgery. Repeat MRI and positron emission tomography (PET) computed tomography revealed an increase in the extent of lesion which required revision decompression. Histopathological examination showed cells with epithelioid appearance, positive for Vimentin, and epitheloid membrane antigen in immunohistochemistry. Radiotherapy was planned but the patient expired due to multiorgan dysfunction. Epithelioid sarcomas are rare soft-tissue neoplasms with poor prognosis. They can mimic infection and a high degree of suspicion is required in these cases to diagnose and treat them early.

Multi-level En Bloc Resection as a Preferred Salvage Therapy for Recurrent Thoracolumbar Chondrosarcoma: A Comparative Study With Piecemeal Resection

STUDY DESIGN

A retrospective analysis was performed.

OBJECTIVE

The aim of this study was to evaluate the feasibility and effectiveness of multilevel en bloc resection versus piecemeal resection for recurrent thoracolumbar chondrosarcoma (CHS).

SUMMARY OF BACKGROUND DATA

Multilevel en bloc resection for recurrent thoracolumbar CHS is rarely performed.

METHODS

Included in this retrospective study were 27 patients with recurrent thoracolumbar CHS who received either multilevel en bloc resection or piecemeal resection as a salvage revision procedure in our center between 2010 and 2018. Relevant data between the two methods were compared. Relapse-free survival (RFS) and overall survival (OS) were analyzed by log-rank analysis.

RESULTS

Our series comprised 16 males and 11 females with a mean age of 40.7 years. Multilevel en bloc resection was performed in 17 patients, and piecemeal resection in 10 patients. Of the 17 patients receiving multilevel en bloc resection, five patients experienced recurrence, of whom three died, whereas in the 10 patients receiving piecemeal resection, seven experienced recurrence and all of them died, showing a significant difference between the two groups (P = 0.04 for recurrence, P = 0.007 for death). Complications occurred more frequently in the patients receiving multilevel en bloc resection (P = 0.04), but RFS and OS were prolonged significantly in this group of patients as compared with piecemeal resection group (56.8 ± 9.7 vs. 17.2 ± 4.2, P = 0.016; 67.3 ± 8.4 vs. 21.4 ± 3.5, P = 0.002).

CONCLUSION

Multilevel en bloc resection as a salvage therapy for recurrent thoracolumbar CHS is technically challenging with high risk of complications, but it can significantly prolong RFS and OS of such patients as compared with piecemeal resection.

LEVEL OF EVIDENCE

4.

Long period of relative quiescence in distal-type epithelioid sarcoma of the forearm with recurrence after surgery: A case report

BACKGROUND

Epithelioid sarcoma (ES) is a rare malignant mesenchymal tumor that only accounts for 0.6% to 1.0% of all cases of sarcomas. ES with a relative quiescent state of more than 10 years is extremely rare.Here, we present a rare case of ES in the forearm of a 17-year-old girl. The patient had a congenital mass in her forearm that measured approximately 1cm; it grew rapidly starting 5 years ago. The mass was not treated until last year when she underwent the first surgery. The mass was located in the middle and lower part of the left forearm and involved the dorsal muscle group, intermuscular space, and subcutaneous tissues without clear boundaries.The patient underwent surgery, and the tumor recurred twice within 1 year postoperatively.

METHODS

The tumor samples were examined via hematoxylin-eosin (HE) and immunohistochemistry staining.

RESULTS

Histopathologically, the tumor comprised large polygonal epithelioid cells with abundant eosinophilic cytoplasm arranged in cell nests. Central necrosis and focal myxoid change could be seen in the tumor tissues. Immunostaining showed that the tumor cells were positive for CD34, CK, EMA, and vimentin but negative for CD31, S-100, and INI-1.

CONCLUSION

Based on these findings, the tumor was diagnosed as ES of distal form. Distal-type ES could have a long period of relative quiescence, after which it could grow rapidly and relapse multiple times over a short duration.

Risk factors of instrumentation failure after multilevel total en bloc spondylectomy

INTRODUCTION

Multilevel total en bloc spondylectomy (TES) is required to secure oncologically adequate resection margins. However, no useful information has been reported for spinal reconstruction after multilevel TES. Therefore, this study set out to assess the clinical and radiological outcomes of spinal reconstruction after multilevel TES.

METHODS

Forty-eight patients treated with multilevel TES at our institute were included in the analysis. Reconstruction was achieved with posterior pedicle screw fixation and an anterior titanium mesh cage filled with iliac autograft in all cases. Spinal shortening was performed to increase spinal stability from the reconstruction. Instrumentation failure and radiological findings were evaluated with radiography and computerized tomography (CT).

RESULTS

After excluding one patient whose general condition was deteriorating, radiological evaluations of 47 patients were performed over a period of more than a year. The follow-up time was 17 to 120 months (mean: 70.2 months). Instrumentation failure occurred in one patient (5.9%) after thoracic multilevel TES, in 4 patients (25.0%) after thoracolumbar multilevel TES, and in 3 patients (42.9%) after lumbar multilevel TES. No instrumentation failure was observed in cervicothoracic cases. Cage subsidence (>2 mm) occurred in 30 patients (63.8%). In 22 of them, subsidence appeared on the CT one month after surgery. The risk factors of instrumentation failure included a multilevel TES below the thoracolumbar level and a long span of vertebral resection. There was no instrumentation failure in any of the 11 "disc-to-disc cutting" cases.

CONCLUSIONS

This study identified the risk factors of instrumentation failure after multilevel TES. There is a high risk of instrumentation failure in cases of long vertebral resection below the thoracolumbar level. On the other hand, our reconstruction method can be successful for multilevel TES above the thoracic level.

Primary leiomyosarcoma of the spine treated with total en bloc spondylectomy: the first case in Thailand-a case report and literature review

Leiomyosarcoma is a rare type of malignant soft tissue tumor and also one of the most aggressive soft tissue sarcomas. It commonly occurs in uterus, abdominal viscera, retroperitoneal space and soft tissue of the extremities. Primary osseous leiomyosarcoma is a rare condition. Furthermore, primary leiomyosarcoma of the spine is extremely rare. Only few cases have been reported. However, the treatment and outcomes remains controversial. Therefore, the objective of this case report is to illustrate the management of this extremely rare disease by using total en bloc spondylectomy (TES) procedure, which is one of a suitable option for surgical resection of the spinal tumors. In this study, we presented an unusual case of a 61-year-old female, who was diagnosed as primary leiomyosarcoma of the twelfth thoracic spine with liver metastasis, treated with total en bloc spondylectomy of the twelfth thoracic vertebra followed by chemotherapy. On last follow-up, 6 months after the surgery, the clinical outcome remained in good condition and no signs of local recurrence. In conclusion, primary leiomyosarcoma of the spine is an extremely rare and difficult to diagnosis. Immunohistochemistry studies are very important for confirmation of the diagnosis. Standard treatment remains controversial. However, surgical resection is still treatment of choice. One of the most effective surgical options is TES, which give the better outcome and minimize local recurrence, if indicate.

Complete Spondylectomy Using Orthogonal Spinal Fixation and Combined Anterior and Posterior Approaches for Thoracolumbar Spinal Reconstruction: Technical Nuances and Clinical Results

STUDY DESIGN

Retrospective chart review.

OBJECTIVE

To determine the long-term efficacy of 2-stage total en bloc spondylectomy (TES).

SUMMARY OF BACKGROUND DATA

TES is a well-described technique to achieve tumor-free margins, but it is a highly destabilizing procedure that necessitates spinal reconstruction. A 2-stage anterior/posterior approach for tumor resection and instrumentation has been shown to be biomechanically superior to the single-stage approach in achieving rigid fixation, but few clinical studies with long-term outcomes exist.

METHODS

A retrospective review was performed on patients undergoing a 2-stage TES for a spinal tumor between 1999 and 2011. Results were compared with those from a literature review of case series, with a minimum of 2-year follow-up, reporting on a single-stage posterior-only approach for TES.

RESULTS

Seven patients were identified (average follow-up 52.7 mo). Tumor location ranged from T1 to L3 with the following pathologies: metastasis (n=3), hemangioma (n=1), leiomyosarcoma (n=1), giant cell tumor (n=1), and chordoma (n=1). There were no significant surgical complications. All 7 patients had intact spinal fixation. There were no failures of the orthogonal fixation (pedicle screws or anterior fixation). The average modified Rankin Scale scores improved from 2.7 preoperatively to 0.7 at last follow-up. None of the patients in our series suffered local disease recurrence at last follow-up or suffered neurological deterioration. These results were comparable with those noted in the literature review of posterior-only approach, where 12% of patients experienced instrument failure.

CONCLUSIONS

TES is a highly destabilizing procedure requiring reconstruction resistant to large multiplanar translational and torsional loads. A 2-stage approach utilizing orthogonal vertebral body screws perpendicular to pedicle screws is a safe and effective surgical treatment strategy. Orthogonal spinal fixation may lower the incidence of instrumentation failure associated with complete spondylectomy and appears to be comparable with a single-stage procedure. However, larger prospective series are necessary to assess the efficacy of this approach versus traditional means.

Epithelioid Sarcoma in the Cervical Spine: A Case Report

Epithelioid sarcoma is a rare and highly malignant soft tissue neoplasm that most commonly occurs in the long bones. This uncommon tumor has a poor clinical outcome, and the modality of its treatment has not yet been fully established. The authors report an extremely rare presentation of epithelioid sarcoma in the cervical spine, along with its clinical progression, imaging, and pathology. The patient underwent three surgical procedures and adjuvant radiochemical management. He survived for 25 months with a good general condition and adapted well to his social activity. Systemic metastasis was not found, but the patient died of respiratory failure due to direct tracheal invasion of the tumor.

Multilevel en bloc spondylectomy for tumors of the thoracic and lumbar spine is challenging but rewarding

BACKGROUND

Over the years, en bloc spondylectomy has proven its efficacy in controlling spinal tumors and improving survival rates. However, there are few reports of large series that critically evaluate the results of multilevel en bloc spondylectomies for spinal neoplasms.

QUESTIONS/PURPOSES

Using data from a large spine tumor center, we answered the following questions: (1) Does multilevel total en bloc spondylectomy result in acceptable function, survival rates, and local control in spinal neoplasms? (2) Is reconstruction after this procedure feasible? (3) What complications are associated with this procedure? (4) is it possible to achieve adequate surgical margins with this procedure?

METHODS

We retrospectively investigated 38 patients undergoing multilevel total en bloc spondylectomy by a single surgeon (AL) from 1994 to 2011. Indications for this procedure were primary spinal sarcomas, solitary metastases, and aggressive primary benign tumors involving multiple segments of the thoracic or lumbar spine. Patients had to be medically fit and have no visceral metastases. Analysis was by chart and radiographic review. Margin quality was classified into intralesional, marginal, and wide. Radiographs, MR images, and CT scans were studied for local recurrence. Graft healing and instrumentation failures at subsequent followup were assessed. Complications were divided into major or minor and further classified as intraoperative and early and late postoperative. We evaluated the oncologic status using cumulative disease-specific and metastases-free survival analysis. Minimum followup was 24 months (mean, 39 months; range, 24-124 months).

RESULTS

Of the 38 patients, 34 (89%) were alive and walking without support at final followup. Thirty-one (81%) had no evidence of disease. Two patients died postoperatively and another two died of systemic disease (without local recurrence). Only three patients (8%) had a local recurrence. There were 14 major complications and 22 minor complications in 25 patients (65%). Only one patient required revision of implants secondary to mechanical failure. Two cases of cage subsidence were noted but had no clinical significance. Wide margins were achieved in nine patients (23%), marginal in 25 (66%), and intralesional in four (11%).

CONCLUSIONS

In patients with multisegmental spinal tumors, oncologic resections were achieved by multilevel en bloc spondylectomy and led to an acceptable survival rate with reasonable local control. Multilevel en bloc surgery was associated with a high complication rate; however, most patients recovered from their complications. Although the surgical procedure is challenging, our encouraging mid-term results clearly favor and validate this technique.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Recurrent adamantinoma in the thoracolumbar spine successfully treated by three-level total en bloc spondylectomy by a single posterior approach

PURPOSE

Adamantinoma is a low-grade primary malignant bone tumour with slow growth and local recurrence. Its occurrence in the spine is extremely rare, particularly with multilevel involvement. This paper wants to present the first case involving a patient with recurrent thoracolumbar spinal adamantinoma, who underwent a successful three-level spondylectomy for en bloc resection.

METHODS

A 24-year-old man with osteolytic masses of T11 and T12 vertebral bodies was performed curettage by a posterior approach in 2008. The pathology report showed the excised neoplasm was a rare adamantinoma. This patient underwent a tumorectomy again because of its local recurrence nearly 3 years later. In 2012, it was unfortunately revealed that the excised tumour had relapsed and had spread to the L1 vertebral body. Due to its repeated recurrence and aggressive lesion, total en bloc spondylectomy (TES) for this malignant tumour was thought to be the best option for preventing repeated recurrence and possible cure. TES for T11-L1 thoracolumbar spine was performed and spinal reconstruction was completed with instrumentation and a titanium mesh cage through a one-stage single posterior approach.

RESULTS

After three-level TES, neurological deficits of the patient demonstrated good recovery and no evidence of adamantinoma recurrence or deformity was found at 2-year follow-up.

CONCLUSIONS

This is the first case involving multilevel thoracolumbar spinal adamantinoma with repeated recurrence to be successfully treated by three-level TES by a single posterior approach.

Four- and five- level en bloc spondylectomy for malignant spinal tumors

STUDY DESIGN

Retrospective study.

OBJECTIVE

To report results of 4- and 5-level en bloc spondylectomy (EBS) in the treatment of malignant spinal tumors.

SUMMARY OF BACKGROUND DATA

EBS is widely used to avoid local recurrence in the treatment of spinal malignant tumors. Four- and 5-level EBS are aggressive procedures associated with complications and morbidity.

METHODS

We conducted a retrospective study of all patients treated with minimum 4-level EBS. Patient and surgical data were noted. Radiographs, magnetic resonance images, and computed tomographic scans were studied for local recurrence, graft, and instrumentation failures at subsequent follow-up. Type of excision was classified into intralesional, marginal, and wide margins. Complications were divided into major or minor and were further classified as intraoperative, early, and late postoperative. At the last follow-up, the patients were classified as alive with no evidence of local or systemic disease, alive with evidence of local or systemic disease or both, dead with evidence of local disease, or systemic disease or both, and dead without evidence of local and systemic disease.

RESULTS

Nine patients were identified who required a minimum 4-level en bloc resection. Five males and 4 females. Average age was 41.66 years (11-66). There were 8 primary malignant tumors: 3 chordomas, 3 osteosarcomas, 1 chondrosarcoma, 1 primary lung tumor and 1 metastatic alveolar soft part sarcoma. Six were operated with 4-level en bloc and 3 with 5 levels. The mean surgical time was 713 minutes and estimated blood loss was 4.5 L. Mean follow-up was 27.7 months (8-84). At the last follow-up, 6 patients were alive with no evidence of local or systemic disease, 1 alive with evidence of systemic disease, 1 dead with evidence of local disease, or systemic disease or both, and 1 DNLS. Only 1 (11%) patient had a local recurrence. Three patients with Frankel D had full neurological recovery. Histopathological assessment showed marginal margins in 7 patients and wide in 2. There were 9 major and 9 minor complications in 7 patients. Five of 7 patients (71%) with complications, had fully recovered from their complications at the last follow-up.

CONCLUSION

Multilevel EBS, can be offered to a patient to prevent local recurrence of disease. Even in experienced hands, the risks of intra- and postoperative complications are high (78%). However, most of the patients with complications, recovered completely (71%). Although the surgery itself may prove beneficial, patients should be well informed regarding the morbidity associated with it.

LEVEL OF EVIDENCE

4.

Clinical outcome of spinal reconstruction after total en bloc spondylectomy at 3 or more levels

STUDY DESIGN

Retrospective clinical study.

OBJECTIVE

To assess the clinical and radiological outcome of spinal reconstruction after total en bloc spondylectomy (TES) at 3 or more levels.

SUMMARY OF BACKGROUND DATA

There have been few reports of multilevel spondylectomy for spinal tumor. This is the first case series on the clinical outcome for reconstructions after 3 or more levels of TES.

METHODS

Twenty-six patients treated by 3 or more levels of TES at Kanazawa University Hospital were included in this analysis. Reconstruction was performed with pedicle screw fixation and a titanium mesh cage filled with autograft in all cases. To increase spinal stability in reconstruction, spinal shortening was performed. Instrument failure and radiological findings were evaluated using radiograph and computed tomographical scan with multiplanar reconstructions. The length of spinal shortening was also measured.

RESULTS

Excluding 4 patients with deteriorating general condition, radiological evaluation was performed for more than 1 year in 22 patients. All 22 patients had no evidence of local recurrence at the surgical site of the spine during the follow-up period. Cage subsidence was seen in 11 patients (50%). Eight of the 11 patients showed the appearance of subsidence 1 month after the surgery. There was one instrument failure that required revision surgery 8 months after TES surgery. One other patient showed bone resorption on the contact surfaces of the cage at 24 months after the surgery. The mean length of the resection vertebrae was 84.6 mm (52-124 mm), while the length of the shortening was 10.4 mm (3-22 mm).

CONCLUSION

No local recurrence was observed after TES at 3 or more levels. Cage subsidence was a common phenomenon (50%) and already observed 1 month after surgery in 8 of the 11 cases. Spinal shortening has the potential to provide good stability for multilevel TES.

LEVEL OF EVIDENCE

4.

Treatment and outcomes of epithelioid sarcoma of the spine

Epithelioid sarcoma (ES) is a rare soft-tissue neoplasm which is most commonly found in the extremities of young adult males. ES has a poor prognosis due to its aggressiveness as it frequently recurs locally and can undergo lymphatic metastasis to soft tissue, fascia, bone, lymph nodes, lung, and brain. The most common form is the classic-type (granuloma-like), though a more aggressive subtype known as the proximal- or axial-type has also been described. As ES of the spine is exceedingly rare, with only seven patients being reported in the literature, the outcomes of these patients is unclear. We have reviewed the literature of all existing spinal ES cases to recommend treatment strategies and report the first case of proximal-type ES in the cervical spine. Patients with spinal ES had an average age of 20.7 years, with 71.4% of cases being in males. Metastasis was common and was found in 83.3% of patients, with lung metastasis being found in 60% of these patients. Due to the high rates of local recurrence and distant metastasis, the goal of surgery remains gross total resection of all tumor and involved bony elements if feasible without significant neurological deficits. Ligation of involved nerve roots may be necessary to achieve adequate resection of the tumor mass as nerve sheaths can serve as a pathway for extension. In the cervical spine, resection of these lesions is difficult due to involvement of the vertebral arteries in addition to nerve roots, increasing the surgical risk.