Two-stage, combined, three-level en bloc spondylectomy for a recurrent post-radiation sarcoma of the lumbar spine

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.

Total en bloc resection of primary and metastatic spine tumors

Primary and metastatic tumors of the spine represent a significant cause of patient morbidity, and present a management challenge to treating providers. From a neurosurgical standpoint, resection surgery may be warranted in cases of spinal instability, progressive disease, neurological compromise, or intractable symptoms. Removal of a tumor "en bloc" offers a more aggressive modality over more conservative resection techniques. En bloc resection entails the removal of the entirety of a tumor without violation of its capsule, and may offer improved rates of local control and overall survival in appropriately selected patients. Conversely, this technique carries a higher complication rate, and requires a unique set of technical skills as compared to more traditional resection. Here, we describe the technical aspects of en bloc resection, as well as specific indications and considerations when employing this operative technique.

Single-stage multi-level construct design incorporating ribs and chest wall reconstruction after en bloc resection of spinal tumour

PURPOSE

Multi-level reconstruction incorporating the chest wall and ribs is technically demanding after multi-segmental total en bloc spondylectomy (TES) of thoracic spinal tumours. Few surgical techniques are reported for effective reconstruction. A novel and straightforward technical reconstruction through posterior-lateral approach was presented to solve the extensive chest wall defect and prevent occurrences of severe respiratory dysfunctions after performing TES. The preliminary outcomes of surgery were reviewed.

METHODS

Multi-level TES was performed for five patients with primary or recurrent thoracic spinal malignancies through posterior-lateral approach. The involved ribs and chest wall were removed to achieve tumour-free margin. Then titanium mesh with allograft bone and pedicle screw-rod system were adopted for the circumferential spinal reconstruction routinely. Titanium rods were modified accordingly to attach to the screw-rod system proximally, and the distal end of rods was dynamically inserted into the ribs.

RESULTS

The mean surgery time was 6.7 hours (range 5-8), with the average blood loss of 3260 ml (range 2300-4500). No severe neurological complications were reported while three patients had complaints of slight numbness of chest skin (no. 1, 3, and 5). No severe respiratory complications occurred during peri-operative period. No implant failure and no local recurrence or distant metastases were observed with an average follow-up of 12.5 months.

CONCLUSIONS

The single-stage reconstructions incorporating spine and chest wall are straightforward and easy to perform. The preliminary outcomes of co-reconstructions are promising and favourable. More studies and longer follow-up are required to validate this technique.

Pleomorphic rhabdomyosarcoma infiltrating thoracic spine in a 59-year-old female patient: Case report

Rhabdomyosarcoma (RMS) represents a malignant tumor of skeletal muscle cells arising from rhabdomyoblasts. RMS represents the most common soft tissue sarcoma in children. In adults it is uncommon and accounts for less than 1% of all malignant solid tumors. While treatment protocols are well known for children, there is no standardized regimen in adults. This is one reason, why the outcome in adults is worse than in children. We present the case of a 59-year-old female patient with pleomorphic rhabdomyosarcoma (PRMS) infiltrating the thoracic spine. Multimodality treatment was performed including en-bloc resection, adjuvant multidrug chemotherapy and radiation beam therapy. The patient was tumor free and had no relapse within 6 month follow-up.

Primary pleomorphic liposarcoma of the spine. Case report and review of the literature

INTRODUCTION

To describe a single case, the fourth ever reported, of pleomorphic liposarcoma of the spine and to undertake a review of the literature.

PRESENTATION OF CASE

A 60 year old male patient had a bilateral lumbosciatica over a 3 month period. Imaging tests revealed a tumor mass in L1-L3 and a fracture in L2. Also, he had a mural thrombus both in the inferior vena cava and the left renal vein. The biopsy revealed a well-differentiated liposarcoma. En bloc resection of the lesion and stabilization was carried out. Due to the condition of the patient (hemodynamic instability, wound dehiscence and infection, and hypoproteinemia), a decision was made not to subject the patient to either radiation therapy or chemotherapy. The patient was subsequently found to suffer from myopathic paraparesis and a surgical wound infection. At three months, liver metastases were evident, as well as a recurrence of the lesion. A venous thrombosis that extended from the lower iliac vein to the right atrium was observed. The patient died from type I hepatorenal syndrome.

DISCUSSION

Pleomorphic liposarcoma of the spine is a rare occurrence. En bloc resection with wide margins is the treatment of choice. The use of radiotherapy in the spine is controversial. The role that should be played by chemotherapy is still unclear, although it has been employed in treatments.

CONCLUSION

In spite of treatment, these tumors lead to a poor prognosis, with high rates of recurrence, metastasis, and mortality.

Radiation-associated sarcoma after recurrent colorectal primary tumor: A complex surgical case

Radiation associated sarcoma is a significant consequence of cancer therapy. Incidence of radiation associated sarcoma correlates with overall radiotherapy exposure. Prognosis is generally poor with 5 year survival rates lower than that for spontaneously occurring sarcomas. Surgical management presents many challenges including having to work in irradiated tissue planes while trying to achieve negative margins. We present a patient with a rare radiation associated pelvic sarcoma whose course illustrates the complexity of this problem.

Surgical site infection after total en bloc spondylectomy: risk factors and the preventive new technology

BACKGROUND CONTEXT

Surgical site infection (SSI) associated with instruments remains a serious and common complication in patients who undergo total en bloc spondylectomy (TES). It is very important that the risk factors for SSI are known to prevent it.

PURPOSE

The purpose of the study was to identify independent risk factors for SSI after TES and evaluate the positive effect of iodine-supported spinal instruments in the prevention of SSI after TES.

STUDY DESIGN

This is a retrospective clinical study.

PATIENT SAMPLE

One hundred twenty-five patients who underwent TES for vertebral tumor were evaluated.

OUTCOME MEASURES

Incidence rate of SSI, risk factors for SSI after TES, and safety of iodine-supported spinal instruments were the outcome measures.

METHODS

Risk factors for SSI were analyzed using logistic regression. In recent 69 patients with iodine-supported spinal instruments, the thyroid hormone levels in the blood were examined to confirm if iodine from the implant influenced thyroid function. Postoperative radiological evaluations were performed regularly.

RESULTS

The rate of SSI was 6.4% (8/125 patients). By multivariate logistic regression, combined anterior and posterior approach and nonuse of iodine-supported spinal instruments were associated with an increased risk of SSI. The rate of SSI without iodine-supported spinal instruments was 12.5%, whereas the rate with iodine-supported spinal instruments was 1.4%. This difference was statistically significant. There were no detected abnormalities of thyroid gland function with the use of iodine-supported instruments. Among the 69 patients with iodine-supported spinal instruments, 2 patients required additional surgery because of instrument failure. However, there were no obvious involvements with the use of iodine-supported spinal instruments.

CONCLUSIONS

This study identified combined anterior and posterior approach and nonuse of iodine-supported spinal instruments to be independent risk factors for SSI after TES. Iodine-supported spinal instrument was extremely effective for prevention of SSI in patients with compromised status, and it had no detection of cytotoxic or adverse effects on the patients.

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.