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Shea GKH, Kwan KYH. Management of Metastatic Spinal Disease - A Practical Approach. Global Spine J 2024:21925682231173646. [PMID: 39069670 DOI: 10.1177/21925682231173646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/30/2024] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVE This review presents a comprehensive approach to the management of spinal metastases. METHODS N/A. RESULTS The wide spectrum of clinical presentation in spinal metastases necessitates a personalized approach to treatment planning. This includes a comprehensive diagnostic workup, oncological management, palliation of symptoms, and surgical intervention if appropriate. A systematic and multidisciplinary approach allows optimal shared decision making to reach an evidence-informed and value-congruent treatment plan for the patient. We highlight how advances in stereotactic body radiotherapy (SBRT) and separation surgery may be incorporated into clinical management from a spine surgeon's perspective. CONCLUSION This review summarizes the approach and management of spinal metastases, its outcomes and complications.
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Affiliation(s)
- Graham Ka Hon Shea
- Department of Orthopaedics and Traumatology, School of Clinical Medicine, The University of Hong Kong, Hong Kong
| | - Kenny Yat Hong Kwan
- Department of Orthopaedics and Traumatology, School of Clinical Medicine, The University of Hong Kong, Hong Kong
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Krauss P, Wolfert CL, Sommer B, Stemmer B, Stueben G, Kahl KH, Shiban E. Intraoperative radiotherapy combined with spinal stabilization surgery-a novel treatment strategy for spinal metastases based on a first single-center experiences. J Neurooncol 2024; 168:445-455. [PMID: 38652400 PMCID: PMC11186943 DOI: 10.1007/s11060-024-04688-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/17/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION Current treatment of spinal metastases (SM) aims on preserving spinal stability, neurological status, and functional status as well as achieving local control. It consists of spinal surgery followed by radiotherapy and/or systemic treatment. Adjuvant therapy usually starts with a delay of a few weeks to prevent wound healing issues. Intraoperative radiotherapy (IORT) has previously been successfully applied during brain tumor, breast and colorectal carcinoma surgery but not in SM, including unstable one, to date. In our case series, we describe the feasibility, morbidity and mortality of a novel treatment protocol for SM combining stabilization surgery with IORT. METHODS Single center case series on patients with SM. Single session stabilization by navigated open or percutaneous procedure using a carbon screw-rod system followed by concurrent 50 kV photon-IORT (ZEISS Intrabeam). The IORT probe is placed via a guide canula using navigation, positioning is controlled by IOCT or 3D-fluroscopy enabling RT isodose planning in the OR. RESULTS 15 (8 female) patients (71 ± 10y) received this treatment between 07/22 and 09/23. Median Spinal Neoplastic Instability Score was 8 [7-10] IQR. Most metastasis were located in the thoracic (n = 11, 73.3%) and the rest in the lumbar (n = 4, 26.7%) spine. 9 (60%) patients received open, 5 (33%) percutaneous stabilization and 1 (7%) decompression only. Mean length of surgery was 157 ± 45 min. Eleven patients had 8 and 3 had 4 screws placed. In 2 patients radiotherapy was not completed due to bending of the guide canula with consecutive abortion of IORT. All other patients received 8 Gy isodoses at mdn. 1.5 cm [1.1-1.9, IQR] depth during 2-6 min. The patients had Epidural Spinal Cord Compression score 1a-3. Seven patients (46.7%) experienced adverse events including 2 surgical site infection (one 65 days after surgery). CONCLUSION 50 kV photon IORT for SM and consecutive unstable spine needing surgical intervention is safe and feasible and can be a promising technique in selected cases.
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Affiliation(s)
- P Krauss
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany.
| | - C L Wolfert
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - B Sommer
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - B Stemmer
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - G Stueben
- Department of Radio Oncology, University Hospital Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - K H Kahl
- Department of Radio Oncology, University Hospital Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - E Shiban
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
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Di Perna G, Baldassarre B, Armocida D, De Marco R, Pesaresi A, Badellino S, Bozzaro M, Petrone S, Buffoni L, Sonetto C, De Luca E, Ottaviani D, Tartara F, Zenga F, Ajello M, Marengo N, Lanotte M, Altieri R, Certo F, Pesce A, Pompucci A, Frati A, Ricardi U, Barbagallo GM, Garbossa D, Cofano F. Application of the NSE score (Neurology-Stability-Epidural compression assessment) to establish the need for surgery in spinal metastases of elderly patients: a multicenter investigation. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024:10.1007/s00586-024-08328-0. [PMID: 38822150 DOI: 10.1007/s00586-024-08328-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 01/08/2024] [Accepted: 05/23/2024] [Indexed: 06/02/2024]
Abstract
PURPOSE This retropective multicentric study aims to investigate the clinical applicability of the NSE score in the elderly, to verify the role of this tool as an easy help for decision making also for this class of patients. METHODS All elderly patients (> 65 years) suffering from spinal metastases undergoing surgical or non-surgical treatment at the authors' Institutions between 2015 and 2022 were recruited. An agreement group (AG) and non-agreement group (NAG) were identified accordingly to the agreement between the NSE score indication and the performed treatment. Neurological status and axial pain were evaluated for both groups at follow-up (3 and 6 months). The same analysis was conducted specifically grouping patients older than 75 years. RESULTS A strong association with improvement or preservation of clinical status (p < 0.001) at follow-up was obtained in AG. The association was not statistically significant in NAG at the 3-month follow-up (p 1.00 and 0.07 respectively) and at 6 months (p 0.293 and 0.09 respectively). The group of patients over 75 years old showed similar results in terms of statistical association between the agreement group and better outcomes. CONCLUSION Far from the need or the aim to build dogmatic algorithms, the goal of preserving a proper performance status plays a key role in a modern oncological management: functional outcomes of the multicentric study group showed that the NSE score represents a reliable tool to establish the need for surgery also for elderly patients.
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Affiliation(s)
- Giuseppe Di Perna
- Spine Surgery Unit, Casa di Cura Città di Bra, Bra, Italy
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco, 15, Turin, 10126, Italy
| | - Bianca Baldassarre
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco, 15, Turin, 10126, Italy
| | - Daniele Armocida
- Neurosurgery Division, Università "La Sapienza" di Roma, Roma, Italy
- Neurosurgery, IRCCS-"Neuromed", Pozzilli, Italy
| | - Raffaele De Marco
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco, 15, Turin, 10126, Italy.
| | - Alessandro Pesaresi
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco, 15, Turin, 10126, Italy
| | - Serena Badellino
- Radiation Oncology, Department of Oncology, University of Turin, Turin, Italy
| | - Marco Bozzaro
- Spine Surgery Unit, Humanitas Gradenigo Hospital, Turin, Italy
| | | | - Lucio Buffoni
- Department of Medical Oncology, Humanitas Gradenigo Hospital, Turin, Italy
- IRCCS Humanitas, Humanitas University, Milan, Italy
| | - Cristina Sonetto
- Department of Medical Oncology, Humanitas Gradenigo Hospital, Turin, Italy
| | - Emmanuele De Luca
- Department of Medical Oncology, Humanitas Gradenigo Hospital, Turin, Italy
| | - Davide Ottaviani
- Department of Medical Oncology, Humanitas Gradenigo Hospital, Turin, Italy
| | - Fulvio Tartara
- Neurosurgery Unit, Istituto Clinico Città Studi, Milan, Italy
| | - Francesco Zenga
- Neurosurgery Unit, "Città della Salute e della Scienza" University Hospital, Turin, Italy
| | - Marco Ajello
- Neurosurgery Unit, "Città della Salute e della Scienza" University Hospital, Turin, Italy
| | - Nicola Marengo
- Neurosurgery Unit, "Città della Salute e della Scienza" University Hospital, Turin, Italy
| | - Michele Lanotte
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco, 15, Turin, 10126, Italy
- Neurosurgery Unit, "Città della Salute e della Scienza" University Hospital, Turin, Italy
| | - Roberto Altieri
- Department of Neurological Surgery, Policlinico "G.Rodolico-S.Marco" University Hospital, Catania, Italy
- Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy
| | - Francesco Certo
- Department of Neurological Surgery, Policlinico "G.Rodolico-S.Marco" University Hospital, Catania, Italy
- Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy
| | - Alessandro Pesce
- Neurosurgery Division, A.O. "Santa Maria Goretti", Latina, Italy
| | - Angelo Pompucci
- Neurosurgery Division, A.O. "Santa Maria Goretti", Latina, Italy
| | | | - Umberto Ricardi
- Radiation Oncology, Department of Oncology, University of Turin, Turin, Italy
| | - Giuseppe Maria Barbagallo
- Department of Neurological Surgery, Policlinico "G.Rodolico-S.Marco" University Hospital, Catania, Italy
- Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy
| | - Diego Garbossa
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco, 15, Turin, 10126, Italy
- Neurosurgery Unit, "Città della Salute e della Scienza" University Hospital, Turin, Italy
| | - Fabio Cofano
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco, 15, Turin, 10126, Italy
- Spine Surgery Unit, Humanitas Gradenigo Hospital, Turin, Italy
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Wang S, Chen Z, Wang K, Li H, Qu H, Mou H, Lin N, Ye Z. Effect of radiotherapy on local control and overall survival in spinal metastasis of non-small-cell lung cancer after surgery and systemic therapy. Bone Jt Open 2024; 5:350-360. [PMID: 38649150 PMCID: PMC11035006 DOI: 10.1302/2633-1462.54.bjo-2024-0037.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
Abstract
Aims Radiotherapy is a well-known local treatment for spinal metastases. However, in the presence of postoperative systemic therapy, the efficacy of radiotherapy on local control (LC) and overall survival (OS) in patients with spinal metastases remains unknown. This study aimed to evaluate the clinical outcomes of post-surgical radiotherapy for spinal metastatic non-small-cell lung cancer (NSCLC) patients, and to identify factors correlated with LC and OS. Methods A retrospective, single-centre review was conducted of patients with spinal metastases from NSCLC who underwent surgery followed by systemic therapy at our institution from January 2018 to September 2022. Kaplan-Meier analysis and log-rank tests were used to compare the LC and OS between groups. Associated factors for LC and OS were assessed using Cox proportional hazards regression analysis. Results Overall, 123 patients with 127 spinal metastases from NSCLC who underwent decompression surgery followed by postoperative systemic therapy were included. A total of 43 lesions were treated with stereotactic body radiotherapy (SBRT) after surgery and 84 lesions were not. Survival rate at one, two, and three years was 83.4%, 58.9%, and 48.2%, respectively, and LC rate was 87.8%, 78.8%, and 78.8%, respectively. Histological type was the only significant associated factor for both LC (p = 0.007) and OS (p < 0.001). Treatment with targeted therapy was significantly associated with longer survival (p = 0.039). The risk factors associated with worse survival were abnormal laboratory data (p = 0.021), lesions located in the thoracic spine (p = 0.047), and lumbar spine (p = 0.044). This study also revealed that postoperative radiotherapy had little effect in improving OS or LC. Conclusion Tumour histological type was significantly associated with the prognosis in spinal NSCLC metastasis patients. In the presence of post-surgical systemic therapy, radiotherapy appeared to be less effective in improving LC, OS, or quality of life in spinal NSCLC metastasis patients.
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Affiliation(s)
- Shengdong Wang
- Department of Orthopedics, Musculoskeletal Tumor Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Institute of Orthopedic Research, Zhejiang University, Hangzhou, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Zehao Chen
- Department of Orthopedics, Musculoskeletal Tumor Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Institute of Orthopedic Research, Zhejiang University, Hangzhou, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Keyi Wang
- Department of Orthopedics, Musculoskeletal Tumor Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Institute of Orthopedic Research, Zhejiang University, Hangzhou, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Hengyuan Li
- Department of Orthopedics, Musculoskeletal Tumor Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Institute of Orthopedic Research, Zhejiang University, Hangzhou, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Hao Qu
- Department of Orthopedics, Musculoskeletal Tumor Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Institute of Orthopedic Research, Zhejiang University, Hangzhou, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Haochen Mou
- Department of Orthopedics, Musculoskeletal Tumor Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Institute of Orthopedic Research, Zhejiang University, Hangzhou, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Nong Lin
- Department of Orthopedics, Musculoskeletal Tumor Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Institute of Orthopedic Research, Zhejiang University, Hangzhou, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Zhaoming Ye
- Department of Orthopedics, Musculoskeletal Tumor Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Institute of Orthopedic Research, Zhejiang University, Hangzhou, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
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Morimoto T, Toda Y, Hakozaki M, Paholpak P, Watanabe K, Kato K, Tsukamoto M, Hirata H, Kaneuchi Y, Tome Y, Nagamine S, Nishida K, Katsuya H, Matsumoto Y, Otani K, Mawatari M, Nikaido T. A new era in the management of spinal metastasis. Front Oncol 2024; 14:1374915. [PMID: 38694784 PMCID: PMC11062132 DOI: 10.3389/fonc.2024.1374915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/02/2024] [Indexed: 05/04/2024] Open
Abstract
Despite the recent advances in cancer treatment, the incidence of patients with spinal metastases continues to grow along with the total number of cancer patients. Spinal metastases can significantly impair activities of daily living (ADL) and quality of life (QOL), compared with other types of bone metastases, as they are characterized with severe pain and paralysis caused by skeletal-related events. Reduced ADL can also lead to treatment limitations as certain anticancer agents and radiation therapy are not compatible treatments; thus, leading to a shorter life expectancy. Consequently, maintaining ADLs in patients with spinal metastases is paramount, and spine surgeons have an integral role to play in this regard. However, neurosurgeon, orthopedic and spinal surgeons in Japan do not have a proactive treatment approach to spinal metastases, which may prevent them from providing appropriate treatment when needed (clinical inertia). To overcome such endemic inertia, it is essential for 1) spine surgeons to understand and be more actively involved with patients with musculoskeletal disorders (cancer locomo) and cancer patients; 2) the adoption of a multidisciplinary approach (coordination and meetings not only with the attending oncologist but also with spine surgeons, radiologists, rehabilitation specialists, and other professionals) to preemptive treatment such as medication, radiotherapy, and surgical treatment; and 3) the integration of the latest findings associated with minimally invasive spinal treatments that have expanded the indications for treatment of spinal metastases and improved treatment outcomes. This heralds a new era in the management of spinal metastases.
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Affiliation(s)
- Tadatsugu Morimoto
- Department of Orthopedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Yu Toda
- Department of Orthopedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Michiyuki Hakozaki
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Permsak Paholpak
- Department of Orthopedics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Kazuyuki Watanabe
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Kinshi Kato
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Masatsugu Tsukamoto
- Department of Orthopedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Hirohito Hirata
- Department of Orthopedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Yoichi Kaneuchi
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yasunori Tome
- Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Satomi Nagamine
- Department of Orthopedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Kotaro Nishida
- Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Hiroo Katsuya
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Yoshihiro Matsumoto
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Koji Otani
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Masaaki Mawatari
- Department of Orthopedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Takuya Nikaido
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
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Ma Y, Cao Y, Cao X, Zhao X, Li Y, Yu H, Lei M, Su X, Zhang B, Huang W, Liu Y. Promoting postoperative recovery in patients with metastatic epidural spinal cord compression based on the concept of ERAS: a multicenter analysis of 304 patients. Spine J 2024; 24:670-681. [PMID: 37918569 DOI: 10.1016/j.spinee.2023.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/25/2023] [Accepted: 10/28/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND CONTEXT Enhanced recovery after surgery (ERAS) has proven beneficial for patients undergoing orthopedic surgery. However, the application of ERAS in the context of metastatic epidural spinal cord compression (MESCC) remains undefined. PURPOSE This study aims to establish a medical pathway rooted in the ERAS concept, with the ultimate goal of scrutinizing its efficacy in enhancing postoperative outcomes among patients suffering from MESCC. STUDY DESIGN/SETTING An observational cohort study. PATIENT SAMPLE A total of 304 patients with MESCC who underwent surgery were collected between January 2016 and January 2023 at two large tertiary hospitals. OUTCOME MEASURES Surgery-related variables, patient quality of life, and pain outcomes. Surgery-related variables in the study included surgery time, surgery site, intraoperative blood loss, and complication. METHODS From January 2020 onwards, ERAS therapies were implemented for MESCC patients in both institutions. Thus, the ERAS cohort included 138 patients with MESCC who underwent surgery from January 2020 to January 2023, whereas the traditional cohort consisted of 166 patients with MESCC who underwent surgery from January 2016 to December 2019. Clinical baseline characteristics, surgery-related features, and surgical outcomes were collected. Patient quality of life was evaluated using the Functional Assessment of Cancer Therapy-General Scale (FACT-G), and pain outcomes were assessed using the Visual Analogue Scale (VAS). RESULTS Comparison of baseline characteristics revealed that the two cohorts were similar (all p>.050), indicating comparable distribution of clinical characteristics. In terms of surgical outcomes, patients in the ERAS cohort exhibited lower intraoperative blood loss (p<.001), shorter postoperative hospital stays (p<.001), lower perioperative complication rates (p=.020), as well as significantly shorter time to ambulation (P<0.001), resumption of regular diet (p<.001), removal of urinary catheter (p<.001), initiation of radiation therapy (p<.001), and initiation of systemic internal therapy (p<.001) compared with patients in the traditional cohort. Regarding pain outcomes and quality of life, patients undergoing the ERAS program demonstrated significantly lower VAS scores (p<.010) and higher scores for physical (p<.001), social (p<.001), emotional (p<.001), and functional (p<.001) well-being compared with patients in the traditional cohort. CONCLUSIONS The ERAS program, renowned for its ability to expedite postoperative recuperation, emerges as a promising approach to ameliorate the recovery process in MESCC patients. Not only does it exhibit potential in enhancing pain management outcomes, but it also holds the promise of elevating the overall quality of life for these individuals. Future investigations should delve deeper into the intricate components of the ERAS program, aiming to unravel the precise mechanisms that underlie its remarkable impact on patient outcomes.
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Affiliation(s)
- Yi Ma
- Department of Lymphoma & Plasma Cell Disease, Senior Department of Hematology, The Fifth Medical Center of PLA General Hospital, No. 8 Dongdajie Street, Fengtai District, Beijing, 100071, China
| | - Yuncen Cao
- Department of Orthopedic Surgery, The Fifth Medical Center of PLA General Hospital, No. 8 Dongdajie Street, Fengtai District, Beijing, 100071, China
| | - Xuyong Cao
- Department of Orthopedic Surgery, The Fifth Medical Center of PLA General Hospital, No. 8 Dongdajie Street, Fengtai District, Beijing, 100071, China
| | - Xiongwei Zhao
- Department of Orthopedic Surgery, The Fifth Medical Center of PLA General Hospital, No. 8 Dongdajie Street, Fengtai District, Beijing, 100071, China; Department of Orthopedic Surgery, The Fifth Medical Center of PLA General Hospital, Fifth School of Clinical Medicine, Anhui Medical University, No. 81 Meishan Road, Hefei, 230032, China
| | - Yue Li
- Department of Oncology, Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, No. 8 Dongdajie Street, Fengtai District, Beijing, 100071, China
| | - Haikuan Yu
- Senior Department of Orthopedic, The Fourth Medical Center of PLA General Hospital, No. 51 Fucheng Rd, Haidian District, Beijing, 100048, China; Chinese PLA Medical School, No. 28 Fuxing Rd, Haidian District, Beijing, 100039, China; Department of Orthopedics, The 927th Hospital of the Joint Service Support Force of the People's Liberation Army of China, No. 3 Yushui Road, Simao District, Pu'er City, 665000, China
| | - Mingxing Lei
- Chinese PLA Medical School, No. 28 Fuxing Rd, Haidian District, Beijing, 100039, China; Department of Orthopedic Surgery, Hainan Hospital of PLA General Hospital, No. 80 Jianglin Rd, Haitang District, Sanya, 572022, China
| | - Xiuyun Su
- Intelligent Medical Innovation institute, Southern University of Science and Technology Hospital, No. 6019 Xili Liuxian Ave, Nanshan District, Shenzhen, 518071, China
| | - Bin Zhang
- Senior Department of Orthopedic, The Fourth Medical Center of PLA General Hospital, No. 51 Fucheng Rd, Haidian District, Beijing, 100048, China; Department of Orthopedic Surgery, The National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, PLA General Hospital, No. 28 Fuxing Rd, Haidian District, Beijing, 100039, China.
| | - Wenrong Huang
- Department of Lymphoma & Plasma Cell Disease, Senior Department of Hematology, The Fifth Medical Center of PLA General Hospital, No. 8 Dongdajie Street, Fengtai District, Beijing, 100071, China.
| | - Yaosheng Liu
- Senior Department of Orthopedic, The Fourth Medical Center of PLA General Hospital, No. 51 Fucheng Rd, Haidian District, Beijing, 100048, China; Department of Orthopedic Surgery, The National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, PLA General Hospital, No. 28 Fuxing Rd, Haidian District, Beijing, 100039, China.
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7
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Ujkic L, Sutanto R, Knöll P, Zarghooni K, Rosenbrock J, Walter S. [Acute spinal cord compression under systemic therapy - radiotherapy or surgery?]. Aktuelle Urol 2024; 55:50-53. [PMID: 37758040 DOI: 10.1055/a-2099-1847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Vertebral bodies are one of the most common metastasis sites found in advanced prostate cancer and have a significant impact on patients' quality of life. Spinal metastases frequently cause severe back pain and in some occasions can lead to secondary complications, with serious neurological deficits and loss of function. The main treatment goals include adequate pain management, controlling tumour growth and restoring spinal stability. Publications on the role of surgery - both conventional and stereotactic radiotherapy, and either as an individual modality or in combination - have been inconclusive. The NOMS score has proven to be useful in making treatment decisions. Existing data show better outcomes in patients with surgical therapy, both when performed in isolation and also combined with radiotherapy, in which some of the cohorts studied including patients with primary cancer other than prostate cancer. Comparative studies that specifically investigate the superiority of specific therapy modalities for metastatic prostate carcinoma are scarce. Similarly, there are limited data on microsurgical interventions for spinal metastases. Radiotherapy alone is crucial in the setting of palliation, especially for pain relief, and its effectiveness has been shown in many studies. The patient's life expectancy plays a crucial role in deciding the most appropriate treatment approach. Given the complexity of the patient population, a multimodal therapy approach is necessary. Current trends in therapy favour greater use of surgical interventions, particularly in the early detection of spinal metastases.
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Affiliation(s)
- Lidija Ujkic
- Klinik für Orthopädie, Unfallchirurgie und plastisch-ästhetische Chirurgie, Uniklinik Köln, Köln, Germany
| | - Ricardo Sutanto
- Klinik für Radioonkologie, Cyberknife und Strahlentherapie, Uniklinik Köln, Köln, Germany
| | - Peter Knöll
- Klinik für Orthopädie, Unfallchirurgie und plastisch-ästhetische Chirurgie, Uniklinik Köln, Köln, Germany
| | - Kourosh Zarghooni
- Klinik für Orthopädie und Unfallchirurgie, HELIOS Klinikum Hildesheim, Hildesheim, Germany
| | - Johannes Rosenbrock
- Klinik für Radioonkologie, Cyberknife und Strahlentherapie, Uniklinik Köln, Köln, Germany
| | - Sebastian Walter
- Klinik für Orthopädie, Unfallchirurgie und plastisch-ästhetische Chirurgie, Uniklinik Köln, Köln, Germany
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Hernández-Fernández A, Pombo-Alonso S, Núñez-Pereira S. Critical evaluation of the literature on decision-making in spinal metastases. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:449-457. [PMID: 36934805 DOI: 10.1016/j.recot.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/08/2023] [Accepted: 03/12/2023] [Indexed: 03/19/2023] Open
Abstract
Decision-making in patients with vertebral metastases is highly complex. Different factors of the patient, their cancer disease and treatment options are involved in it. Treatment schemes and strategies have been modified with the evolution of knowledge and treatment of disseminated oncological disease. This paper analyzes the bibliography that has been used for decision-making in the last three decades, as well as the evolution to the schemes that we could consider contemporary.
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Hernández-Fernández A, Pombo-Alonso S, Núñez-Pereira S. [Translated article] Critical evaluation of the literature on decision-making in spinal metastases. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:S449-S457. [PMID: 37541342 DOI: 10.1016/j.recot.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 03/12/2023] [Indexed: 08/06/2023] Open
Abstract
Decision-making in patients with vertebral metastases is highly complex. Different factors of the patient, their cancer disease and treatment options are involved in it. Treatment schemes and strategies have been modified with the evolution of knowledge and treatment of disseminated oncological disease. This paper analyzes the bibliography that has been used for decision-making in the last three decades, as well as the evolution to the schemes that we could consider contemporary.
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10
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Fuentes Caparrós S, Rodríguez de Tembleque Aguilar F, Marín Luján MÁ, Gutiérrez Castro JA. Preoperative assessment and surgical indications: Separation surgery. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:463-479. [PMID: 37085000 DOI: 10.1016/j.recot.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/05/2023] [Accepted: 04/16/2023] [Indexed: 04/23/2023] Open
Abstract
Neurological compression occurs in 10%-20% of patients who develop spinal metastases. In the last decade, the evolution of oncological diagnostic and medical techniques, the change from conventional external radiation to radiosurgery and the new surgical instruments have meant that the treatment of these patients must be indicated in a personalized manner and by consensus, multidisciplinary way, in specific commissions. Today, the biological state of the patient, the presence of mechanical instability, the neurological assessment and degree of epidural compression, as well as the best prognostic categorization of the tumor, are established as decision factors prior to the indication of surgical treatment, treatment that has passed from a cytoreductive concept to that of a spinal cord release from tumor in order to ensure safe radiosurgery.
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Affiliation(s)
- S Fuentes Caparrós
- Unidad de Columna, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Reina Sofía, Córdoba, España.
| | | | - M Á Marín Luján
- Unidad de Columna, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Reina Sofía, Córdoba, España
| | - J A Gutiérrez Castro
- Unidad de Columna, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Reina Sofía, Córdoba, España
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11
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Fuentes Caparrós S, Rodríguez de Tembleque Aguilar F, Marín Luján MÁ, Gutiérrez Castro JA. [Translated article] Preoperative assessment and surgical indications: Separation surgery. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:S463-S479. [PMID: 37541344 DOI: 10.1016/j.recot.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/16/2023] [Indexed: 08/06/2023] Open
Abstract
Neurological compression occurs in 10%-20% of patients who develop spinal metastases. In the last decade, the evolution of oncological diagnostic and medical techniques, the change from conventional external radiation to radiosurgery and the new surgical instruments have meant that the treatment of these patients must be indicated in a personalized manner and by consensus, multidisciplinary way, in specific commissions. Today, the biological state of the patient, the presence of mechanical instability, the neurological assessment and degree of epidural compression, as well as the best prognostic categorization of the tumor, are established as decision factors prior to the indication of surgical treatment, treatment that has passed from a cytoreductive concept to that of a spinal cord release from tumor in order to ensure safe radiosurgery.
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Affiliation(s)
- S Fuentes Caparrós
- Unidad de Columna, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Reina Sofía, Córdoba, Spain.
| | | | - M Á Marín Luján
- Unidad de Columna, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - J A Gutiérrez Castro
- Unidad de Columna, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Reina Sofía, Córdoba, Spain
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12
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Ong WL, Milne RL, Foroudi F, Millar JL. Stereotactic Body Radiation Therapy for Spine Metastases-Findings from an Australian Population-Based Study. Curr Oncol 2023; 30:7777-7788. [PMID: 37623045 PMCID: PMC10453727 DOI: 10.3390/curroncol30080564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 08/09/2023] [Accepted: 08/20/2023] [Indexed: 08/26/2023] Open
Abstract
Background: To evaluate the use of stereotactic body radiation therapy (SBRT) for spine metastases and the associated factors in Australia. Methods: The Victorian Radiotherapy Minimum Dataset, which captures all episodes of radiotherapy delivered in the state of Victoria, was accessed to evaluate the patterns and trends of SBRT for spine metastases. The primary outcome was SBRT use and associated factors. Results: There were 6244 patients who received 8861 courses of radiotherapy for spine metastases between 2012 and 2017. Of these, 277 (3%) courses were SBRT, which increased from 0.4% in 2012 to 5% in 2017 (P-trend < 0.001). There was a higher proportion of SBRT use in patients with prostate cancer (6%) and melanoma (4%) compared to other cancers (2-3%) (p < 0.001). Patients from the highest socioeconomic quintiles (5%) were more likely to be treated with SBRT compared to patients from the lowest socioeconomic quintiles (3%) (p < 0.001). There was a higher proportion of SBRT use in private radiotherapy centres (6%) compared to public radiotherapy centres (1%) (p < 0.001). No spine SBRT was delivered in regional centres. In multivariate analyses, the year of treatment, age, primary cancers and radiotherapy centres were independently associated with SBRT use. Conclusion: This is the first Australian population-based study quantifying the increasing use of spine SBRT; however, the overall use of spine SBRT remains low. We anticipate an ongoing increase in spine SBRT, as spine SBRT gradually becomes the standard-of-care treatment for painful spine metastases.
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Affiliation(s)
- Wee Loon Ong
- Alfred Health Radiation Oncology, Melbourne 3004, Australia
- Central Clinical School, Monash University, Melbourne 3004, Australia
- School of Clinical Medicine, University of Cambridge, Cambridge CB2 0SP, UK
| | - Roger L. Milne
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne 3004, Australia
- Centre for Epidemiology and Biostatistics, School of Population and Global Health, University of Melbourne, Melbourne 3053, Australia
- Precision Medicine, School of Clinical Sciences, Monash Health, Monash University, Melbourne 3168, Australia
| | - Farshad Foroudi
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness and Research Centre, Austin Health, Heidelberg 3084, Australia
| | - Jeremy L. Millar
- Alfred Health Radiation Oncology, Melbourne 3004, Australia
- Central Clinical School, Monash University, Melbourne 3004, Australia
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13
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Suvithayasiri S, Kim YJ, Liu Y, Trathitephun W, Asawasaksaku A, Quillo-Olvera J, Kotheeranurak V, Chagas H, Valencia CC, Serra MV, Isseldyk FV, Lee LH, Chen CM, Lokhande P, Park SM, Jitpakdee K, Patel KK, Kim JH, Mahatthanatrakul A, Luksanapruksa P, Wilartratsami S, Kim JS. The Role and Clinical Outcomes of Endoscopic Spine Surgery of Treating Spinal Metastases; Outcomes of 29 Cases From 8 Countries. Neurospine 2023; 20:608-619. [PMID: 37401080 PMCID: PMC10323327 DOI: 10.14245/ns.2346274.137] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/08/2023] [Accepted: 04/17/2023] [Indexed: 07/05/2023] Open
Abstract
OBJECTIVE We aim to report the outcomes and feasibility of endoscopic spine surgery used to treat symptomatic spinal metastases patients. This is the most extensive series of spinal metastases patients who underwent endoscopic spine surgery. METHODS A worldwide collaborative network group of endoscopic spine surgeons, named 'ESSSORG,' was established. Patients diagnosed with spinal metastases who underwent endoscopic spine surgery from 2012 to 2022 were retrospectively reviewed. All related patient data and clinical outcomes were gathered and analyzed before the surgery and the followtime period of 2 weeks, 1 month, 3 months, and 6 months. RESULTS A total of 29 patients from South Korea, Thailand, Taiwan, Mexico, Brazil, Argentina, Chile, and India, were included. The mean age was 59.59 years, and 11 of them were female. The total number of decompressed levels was 40. The technique was relatively equal (15 uniportal; 14 biportal). The average length of admission was 4.41 days. Of all patients with an American Spinal Injury Association Impairment Scale of D or lower before surgery, 62.06% reported having at least one recovery grade after the surgery. Almost all clinical outcomes parameters statistically significantly improved and maintained from 2 weeks to 6 months after the surgery. Few surgical-related complications (4 cases) were reported. CONCLUSION Endoscopic spine surgery is a valid option for treating spinal metastases patients as it could yield comparable results to other minimally invasive spine surgery techniques. As the aim is to improve the quality of life, this procedure is valuable and holds value in palliative oncologic spine surgery.
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Affiliation(s)
- Siravich Suvithayasiri
- Department of Neurosurgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Department of Orthopedics, Chulabhorn Hospital, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Young-Jin Kim
- Department of Neurosurgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yanting Liu
- Department of Neurosurgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Warayos Trathitephun
- Department of Orthopedics, Chulabhorn Hospital, Chulabhorn Royal Academy, Bangkok, Thailand
| | | | - Javier Quillo-Olvera
- The Brain and Spine Care, Minimally Invasive Spine Surgery Group, Hospital H+, Queretaro City, Mexico
| | - Vit Kotheeranurak
- Department of Orthopaedics, Faculty of Medicine Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand
| | - Haroldo Chagas
- Department of Neurosurgery, Hospital Federal da Lagoa, Rio de Janeiro, Brazil
| | | | | | | | - Lung-Hsing Lee
- Department of Orthopedics, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
| | - Chien-Min Chen
- Division of Neurosurgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Pramod Lokhande
- Department of Orthopaedics, Smt. Kashibai Navale Medical College and General Hospital, Pune, India
| | - Sang-Min Park
- Spine Center, Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul ational University Bundang Hospital, Seongnam, Korea
| | - Khanathip Jitpakdee
- Department of Neurosurgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Department of Orthopedics, Queen Savang Vadhana Memorial Hospital, Chonburi, Thailand
| | - Kandarpkumar K. Patel
- Department of Neurosurgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung-Hoon Kim
- Department of Neurosurgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | | | - Panya Luksanapruksa
- Division of Spine Surgery, Department of Orthopaedics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sirichai Wilartratsami
- Division of Spine Surgery, Department of Orthopaedics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jin-Sung Kim
- Department of Neurosurgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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14
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Latka K, Kolodziej W, Pawlak K, Sobolewski T, Rajski R, Chowaniec J, Olbrycht T, Tanaka M, Latka D. Fully Endoscopic Spine Separation Surgery in Metastatic Disease-Case Series, Technical Notes, and Preliminary Findings. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050993. [PMID: 37241225 DOI: 10.3390/medicina59050993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 05/28/2023]
Abstract
Objective: This report aims to describe the surgical methodology and potential effectiveness of endoscopic separation surgery (ESS) in patients with metastatic spine disease. This concept may reduce the invasiveness of the procedure, which can potentially speed up the wound healing process and, thus, the possibility of faster application of radiotherapy. Materials and Methods: In this study, separation surgery for preparing patients for stereotactic body radiotherapy (SBRT) was performed with fully endoscopic spine surgery (FESS) followed by percutaneous screw fixation (PSF). Results: Three patients with metastatic spine disease in the thoracic spine were treated with fully endoscopic spine separation surgery. The first case resulted in the progression of paresis symptoms that resulted in disqualification from further oncological treatment. The remaining two patients achieved satisfactory clinical and radiological effects and were referred for additional radiotherapy. Conclusions: With advancements in medical technology, such as endoscopic visualization, and new tools for coagulation, we can treat more and more spine diseases. Until now, spine metastasis was not an indication for the use of endoscopy. This method is very technically challenging and risky, especially at such an early stage of application, due to variations in the patient's condition, morphological diversity, and the nature of metastatic lesions in the spine. Further trials are needed to determine whether this new approach to treating patients with spine metastases is a promising breakthrough or a dead end.
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Affiliation(s)
- Kajetan Latka
- Department of Neurosurgery, St. Hedwig's Regional Specialist Hospital, ul.Wodociagowa 4, 45-221 Opole, Poland
| | - Waldemar Kolodziej
- Department of Neurosurgery, Institute of Medical Sciences, University of Opole, Al.Witosa 26, 45-401 Opole, Poland
| | - Kornel Pawlak
- Department of Radiotherapy, Opole Center of Oncology, ul.Katowicka 66a, 45-061 Opole, Poland
| | - Tomasz Sobolewski
- Department of Neurosurgery, Institute of Medical Sciences, University of Opole, Al.Witosa 26, 45-401 Opole, Poland
| | - Rafal Rajski
- Department of Neurosurgery, Institute of Medical Sciences, University of Opole, Al.Witosa 26, 45-401 Opole, Poland
| | - Jacek Chowaniec
- Department of Neurosurgery, Institute of Medical Sciences, University of Opole, Al.Witosa 26, 45-401 Opole, Poland
| | - Tomasz Olbrycht
- Department of Neurosurgery, Institute of Medical Sciences, University of Opole, Al.Witosa 26, 45-401 Opole, Poland
| | - Masato Tanaka
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama 702-8055, Japan
| | - Dariusz Latka
- Department of Neurosurgery, Institute of Medical Sciences, University of Opole, Al.Witosa 26, 45-401 Opole, Poland
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15
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Nguyen EK, Ruschin M, Zhang B, Soliman H, Myrehaug S, Detsky J, Chen H, Sahgal A, Tseng CL. Stereotactic body radiotherapy for spine metastases: a review of 24 Gy in 2 daily fractions. J Neurooncol 2023; 163:15-27. [PMID: 37155133 DOI: 10.1007/s11060-023-04327-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 04/24/2023] [Indexed: 05/10/2023]
Abstract
PURPOSE Stereotactic body radiotherapy (SBRT) has proven to be a highly effective treatment for selected patients with spinal metastases. Randomized evidence shows improvements in complete pain response rates and local control with lower retreatment rates favoring SBRT, compared to conventional external beam radiotherapy (cEBRT). While there are several reported dose-fractionation schemes for spine SBRT, 24 Gy in 2 fractions has emerged with Level 1 evidence providing an excellent balance between minimizing treatment toxicity while respecting patient convenience and financial strain. METHODS We provide an overview of the 24 Gy in 2 SBRT fraction regimen for spine metastases, which was developed at the University of Toronto and tested in an international Phase 2/3 randomized controlled trial. RESULTS The literature summarizing global experience with 24 Gy in 2 SBRT fractions suggests 1-year local control rates ranging from 83-93.9%, and 1-year rates of vertebral compression fracture ranging from 5.4-22%. Reirradiation of spine metastases that failed prior cEBRT is also feasible with 24 Gy in 2 fractions, and 1-year local control rates range from 72-86%. Post-operative spine SBRT data are limited but do support the use of 24 Gy in 2 fractions with reported 1-year local control rates ranging from 70-84%. Typically, the rates of plexopathy, radiculopathy and myositis are under 5% in those series reporting mature follow up, with no cases of radiation myelopathy (RM) reported in the de novo setting when the spinal cord avoidance structure is limited to 17 Gy in 2 fractions. However, re-irradiation RM has been observed following 2 fraction SBRT. More recently, 2-fraction dose escalation with 28 Gy, with a higher dose constraint to the critical neural tissues, has been reported suggesting improved rates of local control. This regimen may be important in those patients with radioresistant histologies, high grade epidural disease, and/or paraspinal disease. CONCLUSION The dose-fractionation of 24 Gy in 2 fractions is well-supported by published literature and is an ideal starting point for centers looking to establish a spine SBRT program.
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Affiliation(s)
- Eric K Nguyen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Beibei Zhang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
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Colonna S, Bianconi A, Cofano F, Prior A, Di Perna G, Palmieri G, Zona G, Garbossa D, Fiaschi P. Radiofrequency Ablation in Vertebral Body Metastasis with and without Percutaneous Cement Augmentation: A Systematic Review Addressing the Need for SPINE Stability Evaluation. Diagnostics (Basel) 2023; 13:diagnostics13061164. [PMID: 36980472 PMCID: PMC10046948 DOI: 10.3390/diagnostics13061164] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/25/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Vertebral body metastases (VBM) are one of the most frequent sites of bone metastasis, and their adequate therapeutic management still represents an insidious challenge for both oncologists and surgeons. A possible alternative treatment for VBM is radiofrequency ablation (RFA), a percutaneous technique in which an alternating current is delivered to the tumor lesion producing local heating and consequent necrosis. However, RFA alone could alter the biomechanics and microanatomy of the vertebral body, thus increasing the risk of post-procedure vertebral fractures and spine instability, and indeed the aim of the present study is to investigate the effects of RFA on spine stability. A systematic review according to PRISMA-P guidelines was performed, and 17 papers were selected for the systematic review. The results show how RFA is an effective, safe, and feasible alternative to conventional radiotherapy for the treatment of VBM without indication for surgery, but spine stability is a major issue in this context. Although exerting undeniable benefits on pain control and local tumor recurrence, RFA alone increases the risk of spine instability and consequent vertebral body fractures and collapses. Concomitant safe and feasible therapeutic strategies such as percutaneous vertebroplasty and kyphoplasty have shown synergic positive effects on back pain and improvement in spine stability.
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Affiliation(s)
- Stefano Colonna
- Section of Neurosurgery, Department of Neuroscience, AOU Città della Salute e della Scienza, University of Turin, Corso Bramante 88/90, 10126 Turin, Italy
| | - Andrea Bianconi
- Section of Neurosurgery, Department of Neuroscience, AOU Città della Salute e della Scienza, University of Turin, Corso Bramante 88/90, 10126 Turin, Italy
| | - Fabio Cofano
- Section of Neurosurgery, Department of Neuroscience, AOU Città della Salute e della Scienza, University of Turin, Corso Bramante 88/90, 10126 Turin, Italy
- Unità di Chirurgia Vertebrale, Humanitas Gradenigo Hospital, 10100 Turin, Italy
| | - Alessandro Prior
- Section of Neurosurgery, Department of Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili, IRCCS Policlinico San Martino, University of Geneva, Largo Rosanna Benzi, 10, 16132 Genova, Italy
| | - Giuseppe Di Perna
- Unità di Chirurgia Vertebrale, Casa di Cura Città di Bra, 12042 Cuneo, Italy
| | - Giuseppe Palmieri
- Section of Neurosurgery, Department of Neuroscience, AOU Città della Salute e della Scienza, University of Turin, Corso Bramante 88/90, 10126 Turin, Italy
| | - Gianluigi Zona
- Section of Neurosurgery, Department of Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili, IRCCS Policlinico San Martino, University of Geneva, Largo Rosanna Benzi, 10, 16132 Genova, Italy
| | - Diego Garbossa
- Section of Neurosurgery, Department of Neuroscience, AOU Città della Salute e della Scienza, University of Turin, Corso Bramante 88/90, 10126 Turin, Italy
| | - Pietro Fiaschi
- Section of Neurosurgery, Department of Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili, IRCCS Policlinico San Martino, University of Geneva, Largo Rosanna Benzi, 10, 16132 Genova, Italy
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17
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Jing D, Zhao Q, Zhao Y, Lu X, Feng Y, Zhao B, Zhao X. Management of pain in patients with bone metastases. Front Oncol 2023; 13:1156618. [PMID: 37007073 PMCID: PMC10063159 DOI: 10.3389/fonc.2023.1156618] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 03/02/2023] [Indexed: 03/18/2023] Open
Abstract
Cancer-induced bone pain (CIBP) has a considerable impact on patients’ quality of life as well as physical and mental health. At present, patients with CIBP are managed according to the three-step analgesic therapy algorithm proposed by the World Health Organization. Opioids are commonly used as the first-line treatment for moderate-to-severe cancer pain but are limited due to addiction, nausea, vomiting and other gastrointestinal side effects. Moreover, opioids have a limited analgesic effect in some patients. In order to optimize the management of CIBP, we must first identify the underlying mechanisms. In some patients, surgery, or surgery combined with radiotherapy or radiofrequency ablation is the first step in the management of CIBP. Various clinical studies have shown that anti-nerve growth factor (NGF) antibodies, bisphosphonates, or RANKL inhibitors can reduce the incidence and improve the management of cancer pain. Herein, we review the mechanisms of cancer pain and potential therapeutic strategies to provide insights for optimizing the management of CIBP.
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Affiliation(s)
- Doudou Jing
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Qian Zhao
- Department of Endocrine, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Yibo Zhao
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Xiangdong Lu
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Yi Feng
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Bin Zhao
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, Taiyuan, China
- *Correspondence: Bin Zhao, ; Xiaofeng Zhao,
| | - Xiaofeng Zhao
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, Taiyuan, China
- *Correspondence: Bin Zhao, ; Xiaofeng Zhao,
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18
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Kanda Y, Yurube T, Kuroda R, Kakutani K. Separation Surgery and Postoperative Intensity-Modulated Radiation Therapy for a High-Grade Myxofibrosarcoma Involving the Spine: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2023; 24:e939368. [PMID: 36890710 PMCID: PMC10009649 DOI: 10.12659/ajcr.939368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
BACKGROUND Myxofibrosarcoma involving the spine is a rare and intractable disease. Although wide surgical resection is the mainstay of treatment, it is often difficult to complete marginal en-bloc resection due to adjacent neurovascular components in the spine. Separation surgery, a partial resection to achieve circumferential separation and high-dose irradiation such as postoperative intensity-modulated radiation therapy, has received much attention as a new therapy for spinal tumors. However, little evidence regarding separation surgery with intensity-modulated radiation therapy for a spinal myxofibrosarcoma exists. CASE REPORT We present a case of a 75-year-old man with progressive myelopathy. Radiological examination revealed severe spinal cord compression due to an unknown widespread multiple tumor in the cervical and thoracic spine. Computed tomography-guided biopsy showed high-grade sarcoma. Positron emission tomography detected no other tumors in the body. Separation surgery was therefore performed with posterior stabilization. Hematoxylin and eosin staining showed storiform cellular infiltrates and pleomorphic cell nuclei. Histopathology identified high-grade myxofibrosarcoma. Postoperative intensity-modulated radiation therapy of 60 Gy in 25 fractions was completed without any adverse effects. The patient had greatly improved neurological function, was capable of walking with a cane, and had no recurrence for at least 1 year after surgery. CONCLUSIONS We reported a case of an unresectable high-grade myxofibrosarcoma of the spine successfully treated with the combination of separation surgery and postoperative intensity-modulated radiation therapy. This combination therapy is a relatively safe and effective treatment option in patients with impending neurological damage by unresectable sarcomas when total en-bloc resection is challenging due to the size, location, or adhesion.
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Affiliation(s)
- Yutaro Kanda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Takashi Yurube
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Kenichiro Kakutani
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
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Long JR, Kalani MA, Goulding KA, Ashman JB, Flug JA. Carbon-fiber-reinforced polyetheretherketone orthopedic implants in musculoskeletal and spinal tumors: imaging and clinical features. Skeletal Radiol 2023; 52:393-404. [PMID: 35536358 DOI: 10.1007/s00256-022-04069-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/27/2022] [Accepted: 04/27/2022] [Indexed: 02/02/2023]
Abstract
Carbon-fiber-reinforced polyetheretherketone (CFR-PEEK) orthopedic implants are gaining popularity in oncologic applications as they offer many potential advantages over traditional metallic implants. From an imaging perspective, this instrumentation allows for improved evaluation of adjacent anatomic structures during radiography, computed tomography (CT), and magnetic resonance imaging (MRI). This results in improved postoperative surveillance imaging quality as well as easier visualization of anatomy for potential image-guided percutaneous interventions (e.g., pain palliation injections, or ablative procedures for local disease control). CFR-PEEK devices are also advantageous in radiation oncology treatment due to their decreased imaging artifact during treatment planning imaging and decreased dose perturbation during radiotherapy delivery. As manufacturing processes for CFR-PEEK materials continue to evolve and improve, potential orthopedic applications in the spine and appendicular skeleton increase. An understanding of the unique properties of CFR-PEEK devices and their impact on imaging is valuable to radiologists delivering care to orthopedic oncology patients in both the diagnostic and interventional settings. This multidisciplinary review aims to provide a comprehensive insight into the radiologic, surgical, and radiation oncology impact of these innovative devices.
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Affiliation(s)
- Jeremiah R Long
- Department of Radiology, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA.
| | - Maziyar A Kalani
- Department of Neurosurgery, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA
| | - Krista A Goulding
- Department of Orthopedic Surgery, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA
| | - Jonathan B Ashman
- Department of Radiation Oncology, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA
| | - Jonathan A Flug
- Department of Radiology, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA
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20
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Maciejczak A, Gasik R, Kotrych D, Rutkowski P, Antoniak K, Derenda M, Dobiecki K, Górski R, Grzelak L, Guzik G, Harat M, Janusz W, Jarmużek P, Łątka D, Maciejczyk A, Mandat T, Potaczek T, Rocławski M, Trembecki Ł, Załuski R. Spinal tumours: recommendations of the Polish Society of Spine Surgery, the Polish Society of Oncology, the Polish Society of Neurosurgeons, the Polish Society of Oncologic Surgery, the Polish Society of Oncologic Radiotherapy, and the Polish Society of Orthopaedics and Traumatology. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:1300-1325. [PMID: 36854861 DOI: 10.1007/s00586-023-07546-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/31/2022] [Accepted: 01/13/2023] [Indexed: 03/02/2023]
Abstract
PURPOSE The purpose of these recommendations is to spread the available evidence for evaluating and managing spinal tumours among clinicians who encounter such entities. METHODS The recommendations were developed by members of the Development Recommendations Group representing seven stakeholder scientific societies and organizations of specialists involved in various forms of care for patients with spinal tumours in Poland. The recommendations are based on data yielded from systematic reviews of the literature identified through electronic database searches. The strength of the recommendations was graded according to the North American Spine Society's grades of recommendation for summaries or reviews of studies. RESULTS The recommendation group developed 89 level A-C recommendations and a supplementary list of institutions able to manage primary malignant spinal tumours, namely, spinal sarcomas, at the expert level. This list, further called an appendix, helps clinicians who encounter spinal tumours refer patients with suspected spinal sarcoma or chordoma for pathological diagnosis, surgery and radiosurgery. The list constitutes a basis of the network of expertise for the management of primary malignant spinal tumours and should be understood as a communication network of specialists involved in the care of primary spinal malignancies. CONCLUSION The developed recommendations together with the national network of expertise should optimize the management of patients with spinal tumours, especially rare malignancies, and optimize their referral and allocation within the Polish national health service system.
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Affiliation(s)
- A Maciejczak
- Department of Neurosurgery, Szpital Wojewódzki Tarnów, University of Rzeszów, Rzeszów, Poland.
| | - R Gasik
- Department of Neuroorthopedics and Neurology, National Geriatrics, Rheumatology and Rehabilitation Institute, Warsaw, Poland
| | - D Kotrych
- Department of Orthopedics, Traumatology and Musculoskeletal Oncology, Pomeranian Medical University, Szczecin, Poland
| | - P Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - K Antoniak
- Department of Orthopedics, Traumatology and Musculoskeletal Oncology, Pomeranian Medical University, Szczecin, Poland
| | - M Derenda
- Department of Neurosurgery, University of Warmia and Mazury, Olsztyn, Poland
| | - K Dobiecki
- Department of Orthopedics, Traumatology and Musculoskeletal Oncology, Pomeranian Medical University, Szczecin, Poland
| | - R Górski
- Department of Neurosurgery and Spine Surgery, John Paul II Western Hospital, Grodzisk Mazowiecki, Poland
| | - L Grzelak
- Department of Neurosurgery, City Hospital, Toruń, Poland
| | - G Guzik
- Department of Oncologic Orthopedics, Sub-Carpathian Oncology Center, Brzozów, Poland
| | - M Harat
- Department of Oncology and Brachytherapy, Oncology Center Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland
| | - W Janusz
- Department of Orthopedics and Traumatology, Medical University of Lublin, Lublin, Poland
| | - P Jarmużek
- Department of Neurosurgery, University of Zielona Góra, Zielona Góra, Poland
| | - D Łątka
- Department of Neurosurgery, University of Opole, Opole, Poland
| | - A Maciejczyk
- Department of Oncology, Wroclaw Medical University, Wroclaw, Poland
| | - T Mandat
- Department of Nervous System Neoplasms, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - T Potaczek
- Department of Orthopedics and Rehabilitation, University Hospital Zakopane, Jagiellonian University, Kraków, Poland
| | - M Rocławski
- Department of Orthopaedics, Medical University of Gdansk, Gdańsk, Poland
| | - Ł Trembecki
- Department of Oncology, Wroclaw Medical University, Wroclaw, Poland
| | - R Załuski
- Department of Neurosurgery, Wroclaw Medical University, Wroclaw, Poland
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21
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Eysenbach G, Zhai S, Liu X, Chu H, Wei F. The Outcomes of Surgical and Nonsurgical Treatment in Patients With Spinal Metastases of Lung Cancer: Protocol for a Prospective Cohort Study. JMIR Res Protoc 2023; 12:e38273. [PMID: 36716088 PMCID: PMC9926339 DOI: 10.2196/38273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 12/26/2022] [Accepted: 01/12/2023] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Spinal metastases of lung cancer (SMLC) usually have a high degree of malignancy and require multimodality treatment. Patients with SMLC who experience clinical symptoms (eg, local pain, emerging or potential spinal instability, and progressive neurological dysfunction) require surgical treatment. However, there are discrepancies in the comparison of outcomes between surgical treatment and nonsurgical treatment. OBJECTIVE This paper presents the protocol for a study that aims to compare the clinical outcomes of surgical treatment and nonsurgical treatment for SMLC, explore the prognostic factors of SMLC, and establish a survival prediction model based on these prognostic factors. METHODS This is a prospective cohort study, with an anticipated sample size of 240 patients (120 patients in the surgical group and 120 patients in the nonsurgical group). We will collect baseline data, including demographic, clinical, and radiological information, as well as data from patient-reported questionnaires. Patients will be followed up at 3, 6, 12, and 24 months after treatment, and survival status will be assessed every 3 months. The primary outcome is the overall survival period. Prognostic factors associated with overall survival will be analyzed by univariate and multivariate Cox proportional hazards regression. Odds ratios with 95% CIs will be presented. Statistical significance is set at P<.05. RESULTS This study has been approved by our institute's Medical Science Research Ethics Committee (IRB00006761-M2021085) after a careful audit of the design and content. Patient enrollment began in June 2022 at our hospital. Data collection is expected to be completed by early 2026, and the study results will be published by mid-2027. CONCLUSIONS In this study, we propose to set up a prospective cohort of patients with SMLC to investigate the outcomes between surgical treatment and nonsurgical treatment. We will explore the role of surgical treatment in SMLC and provide guidance to peer surgeons. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR2100048151; http://www.chictr.org.cn/showproj.aspx?proj=129450. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/38273.
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Affiliation(s)
| | - Shuheng Zhai
- Department of Orthopedics, Peking University Third Hospital, Beijing, China.,Engineering Research Center of Bone and Joint Precision Medicine, Peking University Third Hospital, Beijing, China.,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
| | - Xiaoxie Liu
- Department of Rehabilitation, Peking University Third Hospital, Beijing, China
| | - Hongling Chu
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Feng Wei
- Department of Orthopedics, Peking University Third Hospital, Beijing, China.,Engineering Research Center of Bone and Joint Precision Medicine, Peking University Third Hospital, Beijing, China.,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
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22
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Marengo N, Di Perna G, Baldassarre BM, Cofano F, De Marco R, Zeppa P, Petrone S, Ajello M, Garbossa D, Zenga F. 3D-printed guides for cervical pedicle screw placement in primary spine tumor: Case report and technical description. Front Surg 2022; 9:1011846. [PMID: 36504577 PMCID: PMC9727165 DOI: 10.3389/fsurg.2022.1011846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 10/24/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction For spine surgeons, dealing with unstable cervical spine has been usually challenging, and this becomes more difficult when facing a primary craniovertebral junction tumor. Primary spine tumor surgery should always include column reconstruction in order to guarantee biomechanical stability of the spine, but surgeons should always be aware that instrumentations could create interferences with postoperative radiations. However, although carbon fiber instrumentations have started to be used in thoracolumbar oncology for few years, these options are still not available for cervical spine. In the reported case, the adopted strategy to obtain adequate column reconstruction was based on the idea of reducing the amount of titanium needed for posterior fixation and maximizing the distance between the radiation target and titanium rods. Case report and aim We present the case of a 53-year-old woman harboring a craniovertebral junction chordoma. A short occipito-C3 construct was selected. Specifically, titanium cervical pedicle screws were placed by using a new technology consisting in patient-tailored and customized 3D-printed guides. The aim of this case report is to determine the feasibility and safety of 3D-printed guides for cervical pedicle screw (CPS) positioning, even in the case of cervical spine tumor. Conclusion CPS could represent a good solution by providing strong biomechanical purchase and tailored 3D-printed guides could increase the safety and the accuracy of this challenging screw placement, even in oncological patients.
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Affiliation(s)
- Nicola Marengo
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy,Skull Base and Pituitary Surgery Unit, AOU Città Della Salute e Della Scienza, Turin, Italy
| | - Giuseppe Di Perna
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy,Spine Surgery Unit, Casa di Cura Clinica Città di Bra, Bra, Italy
| | - Bianca Maria Baldassarre
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy,Skull Base and Pituitary Surgery Unit, AOU Città Della Salute e Della Scienza, Turin, Italy
| | - Fabio Cofano
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy,Spine Surgery Unit, Humanitas Gradenigo Hospital, Turin, Italy
| | - Raffaele De Marco
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy,Skull Base and Pituitary Surgery Unit, AOU Città Della Salute e Della Scienza, Turin, Italy,Correspondence: Raffaele De Marco
| | - Pietro Zeppa
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy
| | - Salvatore Petrone
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy,Spine Surgery Unit, Humanitas Gradenigo Hospital, Turin, Italy
| | - Marco Ajello
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy
| | - Diego Garbossa
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy
| | - Francesco Zenga
- Skull Base and Pituitary Surgery Unit, AOU Città Della Salute e Della Scienza, Turin, Italy
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23
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Muacevic A, Adler JR, Golomohammad R, Sherriff J, Czyz M. Separation Surgery, Fixation With Carbon-Fiber Implants, and Stereotactic Body Radiotherapy for Oligometastatic Spinal Disease. Cureus 2022; 14:e31370. [PMID: 36514641 PMCID: PMC9741859 DOI: 10.7759/cureus.31370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2022] [Indexed: 11/13/2022] Open
Abstract
The management of spinal metastases focuses on reducing symptoms and protecting the spinal cord, historically involving extracorporeal radiotherapy alone. The use of separation surgery techniques alongside high-dose radiotherapy to treat spinal metastases is a novel concept and has changed the treatment paradigm. Additionally, titanium implants have been increasingly used in cases of metastatic spinal tumours requiring adjuvant stereotactic radiotherapy (SBRT). We present the case of a 48-year-old female patient who was diagnosed with a metastatic deposit of breast cancer within L1 with an Epidural Spinal Cord Compression score greater than 1a. At the time of the diagnosis, her prognosis was estimated to be more than two years. She underwent a posterior instrumented fusion of T11-L3 vertebrae with a carbon-fibre fixation system and separation surgery (debulking of the tumour around the spinal cord). The patient was discharged on the second postoperative day achieving complete resolution of the mechanical back pain. SBRT was performed 12 weeks after the surgery. The patient regained ECOG status of 1 shortly after but sadly passed away due to multiple brain metastases 36 months following posterior fixation. Her spinal disease remained well-controlled throughout the follow-up. Carbon-fibre implants appear to be safe and relatively easy to apply. Their use, due to limited artefacts in both computed tomography and magnetic resonance imaging, makes SBRT much more straightforward and follow-up imaging easier to be interpreted. Our experience demonstrates that, in conjunction with separation surgery, the translucent, low perturbing properties of these implants can improve SBRT intervention and detection of recurrence on follow-up imaging.
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24
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Kang DH, Chang BS, Kim H, Hong SH, Chang SY. Separation surgery followed by stereotactic ablative radiotherapy for metastatic epidural spinal cord compression: A systematic review and meta-analysis for local progression rate. J Bone Oncol 2022; 36:100450. [PMID: 35990514 PMCID: PMC9386097 DOI: 10.1016/j.jbo.2022.100450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/22/2022] [Accepted: 07/31/2022] [Indexed: 11/10/2022] Open
Abstract
The pooled 1-year local progression rate of hybrid therapy in spinal metastasis was 10.2%. The pooled 2-year local progression rate of hybrid therapy in spinal metastasis was 13.7%. A lower radiation dose per fraction showed a significant association with the 1-year local progression rate of hybrid therapy in spinal metastasis. History of prior radiotherapy showed a significant association with the 1-year local progression rate of hybrid therapy in spinal metastasis. Colorectal cancer showed a significant association with the 1-year local progression rate of hybrid therapy in spinal metastasis.
Introduction Spinal metastasis is the most common metastatic skeletal disease in cancer patients. Metastatic epidural spinal cord compression (MESCC), which occurs in 5–14% of cancer patients, is an oncological emergency because it may cause a permanent neurological deficit. Separation surgery followed by stereotactic ablative radiotherapy (SABR), so-called “hybrid therapy,” has shown effectiveness in local control of spinal metastasis and has become an integral treatment option for patients with MESCC. Therefore, we performed a meta-analysis and meta-regression analysis to clarify the local progression rate of hybrid therapy and the risk factors for local progression. Methods We searched PubMed, EMBASE, Scopus, Cochrane Library, and Web of Science databases from inception to December 2021. Meta-analyses of proportions were used to analyze the data using a random-effects model to calculate the pooled 1-year local progression rate and confidence interval. Subgroup analyses were performed using meta-analyses of odds ratio (OR) for comparisons between groups. We also conducted a meta-regression analysis to identify the factors that caused heterogeneity. Results A total of 661 patients from 13 studies (10 retrospective and 3 prospective) were included in the final meta-analysis. The quality of the included studies assessed using the Newcastle − Ottawa scale ranged from poor to fair (range, 4–6). The pooled local progression rate was 10.2 % (95 % confidence interval [CI], 7.8–12.8 %; I2 = 30 %) and 13.7 % (95 % CI, 9.3–18.8 %; I2 = 55 %) at postoperative 1 and 2 years, respectively. The subgroup analysis indicated that patients with a history of prior radiotherapy (OR, 5.14; 95 % CI, 1.71–15.51) and lower radiation dose per fraction (OR, 4.57; 95 % CI, 1.88–11.13) showed significantly higher pooled 1-year local progression rates. In the moderator analysis, the 1-year local progression rate was significantly associated with the proportion of patients with a history of prior radiotherapy (p = 0.036) and those with colorectal cancer as primary origin (p < 0.001). Conclusions The pooled 1-year local progression rate of hybrid therapy for MESCC was 10.2%. In subgroup and moderator analyses, a lower radiation dose per fraction, history of prior radiotherapy, and colorectal cancer showed a significant association with the 1-year local progression rate.
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Key Words
- CT, computed tomography
- CTV, clinical target volume
- GTV, gross tumor volume
- Gy, Gray
- Hybrid therapy
- Local progression
- MESCC, metastatic epidural spinal cord compression
- MOOSE, Meta-Analysis of Observational Studies in Epidemiology
- MRI, magnetic resonance imaging
- PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- PTV, planning target volume
- Radioresistance
- SABR, stereotactic ablative radiotherapy
- Separation surgery
- Spinal metastasis
- Stereotactic ablative radiotherapy
- cEBRT, conventional external beam radiation therapy
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Affiliation(s)
- Dong-Ho Kang
- Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Hospital, 101 Daehangno, Jongno-gu, Seoul, Republic of Korea
| | - Bong-Soon Chang
- Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Hospital, 101 Daehangno, Jongno-gu, Seoul, Republic of Korea
| | - Hyoungmin Kim
- Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Hospital, 101 Daehangno, Jongno-gu, Seoul, Republic of Korea
| | - Seong Hwa Hong
- Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Hospital, 101 Daehangno, Jongno-gu, Seoul, Republic of Korea
| | - Sam Yeol Chang
- Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Hospital, 101 Daehangno, Jongno-gu, Seoul, Republic of Korea
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Dobran M, Lisi SV, Di Rienzo A, Carrassi E, Capece M, Dorato P, di Somma LGM, Iacoangeli M. Evaluation of prognostic preoperative factors in patients undergoing surgery for spinal metastases: Results in a consecutive series of 81 cases. Surg Neurol Int 2022; 13:363. [PMID: 36128147 PMCID: PMC9479529 DOI: 10.25259/sni_276_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/06/2022] [Indexed: 12/03/2022] Open
Abstract
Background: Surgical treatment of spinal metastases should be tailored to provide pain control, neurological deficit improvement, and vertebral stability with low operative morbidity and mortality. The aim of this study was to analyze the predictive value of some preoperative factors on overall survival in patients undergoing surgery for spinal metastases. Methods: We retrospectively analyzed a consecutive series of 81 patients who underwent surgery for spinal metastases from 2015 and 2021 in the Clinic of Neurosurgery of Ancona (Italy). Data regarding patients’ baseline characteristics, preoperative Karnofsky Performance Status Score (KPS), and Frankel classification grading system, histology of primary tumor, Tokuhashi revised and Tomita scores, Spine Instability Neoplastic Score, and Epidural Spinal Cord Compression Classification were collected. We also evaluated the interval time between the diagnosis of the primary tumor and the onset of spinal metastasis, the type of surgery, the administration of adjuvant therapy, postoperative pain and Frankel grade, and complications after surgery. The relationship between patients’ overall survival and predictive preoperative factors was analyzed by the Kaplan–Meier method. For the univariate and multivariate analysis, the log-rank test and Cox regression model were used. P ≤ 0.05 was considered as statistically significant. Results: After surgery, the median survival time was 13 months. In our series, the histology of the primary tumor (P < 0.001), the Tomita (P < 0.001) and the Tokuhashi revised scores (P < 0.001), the preoperative KPS (P < 0.001), the adjuvant therapy (P < 0.001), the postoperative Frankel grade (P < 0.001), and the postoperative pain improvement (P < 0.001) were significantly related to overall survival in the univariate analysis. In the multivariate analysis, the Tomita (P < 0.001), Tokuhashi revised scores (P < 0.001), and the adjuvant therapy were confirmed as independent prognostic factors. Conclusion: These data suggest that patients with limited extension of primitive tumor and responsive to the adjuvant therapy are the best candidates for surgery with better outcome.
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26
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Radiation myelopathy following stereotactic body radiation therapy for spine metastases. J Neurooncol 2022; 159:23-31. [PMID: 35737172 DOI: 10.1007/s11060-022-04037-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 05/13/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE Stereotactic body radiation therapy (SBRT) is now considered a standard of care treatment option in the management of spine metastases. One of the most feared complications of spine SBRT is radiation myelopathy (RM). METHODS We provided a narrative review of RM following spine SBRT based on review of the published literature, including data on spinal cord dose constraints associated with the risk of RM, strategies to mitigate the risk, and management options for RM. RESULTS There are limited published data of cases of RM following spine SBRT with detailed spinal cord dosimetry. The HyTEC report provided recommendations for the point maximal dose (Dmax) for the spinal cord that is associated with a < 5% risk of RM for 1-5 fractions spine SBRT. In the setting of spine SBRT reirradiation after previous conventional external beam radiation therapy (cEBRT), factors associated with RM are: SBRT spinal cord Dmax, cumulative spinal cord Dmax, and the time interval between previous RT and SBRT reirradiation. There are various strategies to mitigate the risk of RM, including accurate delineation of the spinal cord (or thecal sac), strict adherence to the recommended spinal cord dose constraints, and robust treatment immobilisation set-up and delivery. Limited effective treatment options are available for patients who develop RM, and these include corticosteroids, hyperbaric oxygen, and bevacizumab; however, none have been supported by high quality evidence. CONCLUSION RM is a rare but devastating complication following SBRT for spine metastases. There are strategies to minimise the risk of RM to ensure safe delivery of spine SBRT.
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27
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Lin J, Zhu X, Tang Q, Lu J, Xu H, Song G, Deng C, Wu H, Huang Y, Huang A, Xu Y, Chen H, Wang J. Minimally invasive separation surgery for the treatment of spinal metastases with small incision and freehand pedicle screw fixation: the surgical learning curve. BMC Musculoskelet Disord 2022; 23:273. [PMID: 35317753 PMCID: PMC8939122 DOI: 10.1186/s12891-022-05191-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 03/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Minimally invasive separation surgery (MISS) is a safe and effective surgical technique, the current optimal treatment for spinal metastases. However, the learning curve for this technique has not been analyzed. This study aimed to define and analyze the surgical learning curve of MISS for the treatment of spinal metastases with small incision and freehand pedicle screw fixation. METHODS A continuous series of 62 patients with spinal metastases who underwent MISS were included. Each patient's operative data were accurately counted. The improvement of the patients' neurological function was followed up after surgery to evaluate the surgical treatment effect. Logarithmic curve-fit regression was used to analyze the surgical learning curve of MISS. The number of cases needed to achieve proficiency was analyzed. Based on this cut-off point, this series of cases was divided into the early phase and later phase groups. The influence of the time sequence of MISS on surgical data and surgical efficacy was analyzed. RESULTS The operative time decreased gradually with the number of surgical cases increasing and stabilized after the 20th patient. There was no statistical difference in demographic characteristics and preoperative characteristics between the two groups. The mean operative time in the later phase group was about 39 min shorter than that in the early phase group (mean 227.95 vs. 189.02 min, P = 0.027). However, it did not affect other operative data or the surgical treatment effect. CONCLUSION The learning curve of MISS for spinal metastases is not steep. With the increase of surgeons' experience, the operative time drops rapidly and stabilizes within a certain range. MISS can be safely and effectively performed at the beginning of a surgeon's caree.
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Affiliation(s)
- Jiaming Lin
- Department of Musculoskeletal Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng East Road, Guangzhou, 510060, Guangdong, China
| | - Xiaojun Zhu
- Department of Musculoskeletal Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng East Road, Guangzhou, 510060, Guangdong, China
| | - Qinglian Tang
- Department of Musculoskeletal Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng East Road, Guangzhou, 510060, Guangdong, China
| | - Jinchang Lu
- Department of Musculoskeletal Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng East Road, Guangzhou, 510060, Guangdong, China
| | - Huaiyuan Xu
- Department of Musculoskeletal Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng East Road, Guangzhou, 510060, Guangdong, China
| | - Guohui Song
- Department of Musculoskeletal Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng East Road, Guangzhou, 510060, Guangdong, China
| | - Chuangzhong Deng
- Department of Musculoskeletal Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng East Road, Guangzhou, 510060, Guangdong, China
| | - Hao Wu
- Department of Musculoskeletal Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng East Road, Guangzhou, 510060, Guangdong, China
| | - Yufeng Huang
- Department of Musculoskeletal Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng East Road, Guangzhou, 510060, Guangdong, China
| | - Anfei Huang
- Department of Musculoskeletal Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng East Road, Guangzhou, 510060, Guangdong, China
| | - Yanyang Xu
- Department of Musculoskeletal Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng East Road, Guangzhou, 510060, Guangdong, China
| | - Hongmin Chen
- Department of Musculoskeletal Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng East Road, Guangzhou, 510060, Guangdong, China
| | - Jin Wang
- Department of Musculoskeletal Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng East Road, Guangzhou, 510060, Guangdong, China.
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Hu X, Huang W, Sun Z, Ye H, Man K, Wang Q, Sun Y, Yan W. Predictive factors, preventive implications, and personalized surgical strategies for bone metastasis from lung cancer: population-based approach with a comprehensive cancer center-based study. EPMA J 2022; 13:57-75. [PMID: 35273659 PMCID: PMC8897531 DOI: 10.1007/s13167-022-00270-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/03/2022] [Indexed: 10/19/2022]
Abstract
Background Bone metastasis (BM) and skeletal-related events (SREs) happen to advanced lung cancer (LC) patients without warning. LC-BM patients are often passive to BM diagnosis and surgical treatment. It is necessary to guide the diagnosis and treatment paradigm for LC-BM patients from reactive medicine toward predictive, preventive, and personalized medicine (PPPM) step by step. Methods Two independent study cohorts including LC-BM patients were analyzed, including the Surveillance, Epidemiology, and End Results (SEER) cohort (n = 203942) and the prospective Fudan University Shanghai Cancer Center (FUSCC) cohort (n = 59). The epidemiological trends of BM in LC patients were depicted. Risk factors for BM were identified using a multivariable logistic regression model. An individualized nomogram was developed for BM risk stratification. Personalized surgical strategies and perioperative care were described for FUSCC cohort. Results The BM incidence rate in LC patients grew (from 17.53% in 2010 to 19.05% in 2016). Liver metastasis was a significant risk factor for BM (OR = 4.53, 95% CI = 4.38-4.69) and poor prognosis (HR = 1.29, 95% CI = 1.25-1.32). The individualized nomogram exhibited good predictive performance for BM risk stratification (AUC = 0.784, 95%CI = 0.781-0.786). Younger patients, males, patients with high invasive LC, and patients with other distant site metastases should be prioritized for BM prevention. Spine is the most common site of BM, causing back pain (91.5%), pathological vertebral fracture (27.1%), and difficult walking (25.4%). Spinal surgery with personalized spinal reconstruction significantly relieved pain and improved daily activities. Perioperative inflammation, immune, and nutrition abnormities warrant personalized managements. Radiotherapy needs to be recommended for specific postoperative individuals. Conclusions The presence of liver metastasis is a strong predictor of LC-BM. It is recommended to take proactive measures to prevent BM and its SREs, particularly in young patients, males, high invasive LC, and LC with liver metastasis. BM surgery and perioperative management are personalized and required. In addition, adjuvant radiation following separation surgery must also be included in PPPM-guided management. Graphical abstract Supplementary Information The online version contains supplementary material available at 10.1007/s13167-022-00270-9.
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Affiliation(s)
- Xianglin Hu
- grid.452404.30000 0004 1808 0942Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032 China ,grid.11841.3d0000 0004 0619 8943Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032 China
| | - Wending Huang
- grid.452404.30000 0004 1808 0942Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032 China ,grid.11841.3d0000 0004 0619 8943Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032 China
| | - Zhengwang Sun
- grid.452404.30000 0004 1808 0942Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032 China ,grid.11841.3d0000 0004 0619 8943Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032 China
| | - Hui Ye
- grid.267313.20000 0000 9482 7121Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX 75390 USA
| | - Kwong Man
- grid.259384.10000 0000 8945 4455Department of General Surgery, University Hospital of Macau University of Science and Technology, Macau, 999078 China
| | - Qifeng Wang
- grid.452404.30000 0004 1808 0942Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, 200032 China
| | - Yangbai Sun
- grid.452404.30000 0004 1808 0942Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032 China ,grid.11841.3d0000 0004 0619 8943Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032 China
| | - Wangjun Yan
- grid.452404.30000 0004 1808 0942Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032 China ,grid.11841.3d0000 0004 0619 8943Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032 China
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Thureau S, Rogé M, Marchesi V, Hadj Henni A, Faivre JC. [Stereotactic body radiation therapy for spine bone oligometastatic disease]. Cancer Radiother 2021; 25:830-836. [PMID: 34716092 DOI: 10.1016/j.canrad.2021.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 08/19/2021] [Accepted: 08/22/2021] [Indexed: 10/20/2022]
Abstract
Stereotactic radiotherapy is an ever more common technique, regardless of the location treated. However, spinal stereotactic radiotherapy requires a particular technicality in order to ensure its proper realization. There is now a large literature defining the type of imaging to be used, the dose to be delivered and the delineation of target volumes. This technique can achieve a significant local control and an interesting analgesic efficiency. However, its place in relation to conventional radiotherapy remains limited because it requires MRI imaging and a significantly longer patient management during the treatment fraction. In this context, it is currently mainly restricted to oligometastatic patients or for re-irradiations.
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Affiliation(s)
- S Thureau
- Département de radiothérapie et de physique médicale, centre Henri-Becquerel-CLCC-Unicancer, Quantif-Litis EA 4108, rue d'Amiens, 76038 Rouen, France.
| | - M Rogé
- Département de radiothérapie et de physique médicale, centre Henri-Becquerel-CLCC-Unicancer, Quantif-Litis EA 4108, rue d'Amiens, 76038 Rouen, France
| | - V Marchesi
- Lorraine Institute of Cancerology-Alexis-Vautrin Comprehensive Cancer Center, Academic Radiation Oncology & Brachytherapy Department, 6, avenue de Bourgogne, Vandoeuvre Lès Nancy 4519, France
| | - A Hadj Henni
- Département de radiothérapie et de physique médicale, centre Henri-Becquerel-CLCC-Unicancer, Quantif-Litis EA 4108, rue d'Amiens, 76038 Rouen, France
| | - J C Faivre
- Lorraine Institute of Cancerology-Alexis-Vautrin Comprehensive Cancer Center, Academic Radiation Oncology & Brachytherapy Department, 6, avenue de Bourgogne, Vandoeuvre Lès Nancy 4519, France
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Baldassarre BM, Di Perna G, Portonero I, Penner F, Cofano F, Marco RD, Marengo N, Garbossa D, Pecorari G, Zenga F. Craniovertebral junction chordomas: Case series and strategies to overcome the surgical challenge. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:420-431. [PMID: 35068826 PMCID: PMC8740819 DOI: 10.4103/jcvjs.jcvjs_87_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 09/28/2021] [Indexed: 11/04/2022] Open
Abstract
Introduction: Chordomas are rare and malignant primary bone tumors. Different strategies have been proposed for chordomas involving the craniovertebral junction (CVJ) compared to other locations. The impossibility to achieve en bloc excision, the impact on stability and the need for proper reconstruction make their surgical management challenging. Objective: The objective is to discuss surgical strategies in CVJ chordomas operated in a single-center during a 7 years' experience (2013-2019). Methods: Adult patients with CVJ chordoma were retrospectively analyzed. The clinical, radiological, pathological, and surgical data were discussed. Results: A total number of 8 patients was included (among a total number of 32 patients suffering from skull base chordoma). Seven patients underwent endoscopic endonasal approach (EEA), and posterior instrumentation was needed in three cases. Three explicative cases were reported: EEA for midline tumor involving lower clivus and upper cervical spine (case 1), EEA and complemental posterior approach for occurred occipitocervical instability (case 2), C2 chordoma which required aggressive bone removal and consequent implant positioning, focusing on surgical planning (timing and type of surgical stages, materials and customization of fixation system) (case 3). Conclusion: EEA could represent a safe route to avoid injuries to neurovascular structure in clival locations, while a combined approach could be considered when tumor spreads laterally. Tumor involvement or surgical procedures could give raise to CVJ instability with the need of complementary posterior instrumentation. Thus, a tailored preoperative planning should play a key role, especially when aggressive bone removal and implant positioning are needed.
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Affiliation(s)
- Bianca Maria Baldassarre
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Giuseppe Di Perna
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Irene Portonero
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Federica Penner
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy.,Spine Surgery Unit, Humanitas Cellini Hospital, Turin, Italy
| | - Fabio Cofano
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy.,Spine Surgery Unit, Humanitas Gradenigo Hospital, Turin, Italy
| | - Raffaele De Marco
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Nicola Marengo
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Diego Garbossa
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Giancarlo Pecorari
- Department of Surgical Sciences, ENT Surgery Unit, University of Turin, Turin, Italy
| | - Francesco Zenga
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
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Cofano F, Di Perna G, Tartara F, Marengo N, Ajello M, Bozzaro M, Zenga F, Garbossa D. Letter to the Editor Regarding "COVID-19: A Time Like No Other in (the Department of) Neurological Surgery". Should We Broaden Surgical Indications to Preserve the Standard of Care in Spinal Metastases? World Neurosurg 2021; 151:303-304. [PMID: 34243645 PMCID: PMC8256388 DOI: 10.1016/j.wneu.2021.03.154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 11/02/2022]
Affiliation(s)
- Fabio Cofano
- Spine Surgery Unit, Humanitas Gradenigo Hospital, Turin, Italy; Department of Neuroscience "Rita Levi Montalcini," Neurosurgery Unit, University of Turin, Turin, Italy.
| | - Giuseppe Di Perna
- Department of Neuroscience "Rita Levi Montalcini," Neurosurgery Unit, University of Turin, Turin, Italy
| | | | - Nicola Marengo
- Department of Neuroscience "Rita Levi Montalcini," Neurosurgery Unit, University of Turin, Turin, Italy
| | - Marco Ajello
- Department of Neuroscience "Rita Levi Montalcini," Neurosurgery Unit, University of Turin, Turin, Italy
| | - Marco Bozzaro
- Spine Surgery Unit, Humanitas Gradenigo Hospital, Turin, Italy
| | - Francesco Zenga
- Department of Neuroscience "Rita Levi Montalcini," Neurosurgery Unit, University of Turin, Turin, Italy
| | - Diego Garbossa
- Department of Neuroscience "Rita Levi Montalcini," Neurosurgery Unit, University of Turin, Turin, Italy
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Neal MT, Richards AE, Curley KL, Patel NP, Ashman JB, Vora SA, Kalani MA. Carbon fiber-reinforced PEEK instrumentation in the spinal oncology population: a retrospective series demonstrating technique, feasibility, and clinical outcomes. Neurosurg Focus 2021; 50:E13. [PMID: 33932921 DOI: 10.3171/2021.2.focus20995] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 02/17/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors aimed to demonstrate the feasibility and advantages of carbon fiber-reinforced PEEK (CFRP) composite implants in patients with both primary and secondary osseous spinal tumors. METHODS Twenty-eight spinal tumor patients who underwent fixation with CFRP hardware were retrospectively identified in a Spine Tumor Quality Database at a single institution. Demographic, procedural, and follow-up data were retrospectively collected. RESULTS The study population included 14 females and 14 males with a mean age of 60 years (range 30-86 years). Five patients had primary bone tumors, and the remaining patients had metastatic tumors. Breast cancer was the most common metastatic tumor. The most common presenting symptom was axial spine pain (25 patients, 89%), and the most common Spine Instability Neoplastic Score was 7 (range 6-14). Two patients in this series had anterior cervical procedures. The remaining patients underwent posterior thoracolumbar fixation. The average fusion length included 4.6 vertebral segments (range 3-8). The mean clinical follow-up time with surgical or oncology teams was 6.5 months (range 1-23 months), and the mean interval for last follow-up imaging (CT or MRI) was 6.5 months (range 1-22 months). Eighteen patients received postoperative radiation at the authors' institution (16 with photon therapy, 2 with proton therapy). Eleven of the patients (39%) in this series died. At the last clinical follow-up, 26 patients (93%) had stable or improved neurological function compared with their preoperative status. At the last imaging follow-up, local disease control was observed in 25 patients (89%). Two patients required reoperation in the immediate postoperative period, one for surgical site infection and the other for compressive epidural hematoma. One patient was noted to have lucencies around the most cephalad screws 3 months after surgery. No hardware fracture or malfunction occurred intraoperatively. No patients required delayed surgery for hardware loosening, fracture, or other failure. Early tumor recurrence was detected in 3 patients. Early detection was attributed to the imaging characteristics of the CFRP hardware. CONCLUSIONS CFRP spinal implants appear to be safe and comparable to conventional titanium implants in terms of functionality. The imaging characteristics of CFRP hardware facilitate radiation planning and assessment of surveillance imaging. CFRP hardware may enhance safety and efficacy, particularly with particle therapy dosimetry. Larger patient populations with longer-term follow-up are needed to confirm the various valuable aspects of CFRP spinal implants.
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Affiliation(s)
| | | | | | | | | | - Sujay A Vora
- 2Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona
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Echt M, Stock A, De la Garza Ramos R, Der E, Hamad M, Holland R, Cezayirli P, Nasser R, Yanamadala V, Yassari R. Separation surgery for metastatic epidural spinal cord compression: comparison of a minimally invasive versus open approach. Neurosurg Focus 2021; 50:E10. [PMID: 33932918 DOI: 10.3171/2021.2.focus201124] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 02/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to compare outcomes of separation surgery for metastatic epidural spinal cord compression (MESCC) in patients undergoing minimally invasive surgery (MIS) versus open surgery. METHODS A retrospective study of patients undergoing MIS or standard open separation surgery for MESCC between 2009 and 2019 was performed. Both groups received circumferential decompression via laminectomy and a transpedicular approach for partial corpectomy to debulk ventral epidural disease, as well as instrumented stabilization. Outcomes were compared between the two groups. RESULTS There were 17 patients in the MIS group and 24 in the open surgery group. The average age of the MIS group was significantly older than the open surgery group (65.5 vs 56.6 years, p < 0.05). The preoperative Karnofsky Performance Scale score of the open group was significantly lower than that of the MIS group, with averages of 63.0% versus 75.9%, respectively (p = 0.02). This was also evidenced by the higher proportion of emergency procedures performed in the open group (9 of 24 patients vs 0 of 17 patients, p = 0.004). The average Spine Instability Neoplastic Score, number of levels fused, and operative parameters, including length of stay, were similar. The average estimated blood loss difference for the open surgery versus the MIS group (783 mL vs 430 mL, p < 0.05) was significant, although the average amount of packed red blood cells transfused was not significantly different (325 mL vs 216 mL, p = 0.39). Time until start of radiation therapy was slightly less in the MIS than the open surgery group (32.8 ± 15.6 days vs 43.1 ± 20.3 days, p = 0.069). Among patients who underwent open surgery with long-term follow-up, 20% were found to have local recurrence compared with 12.5% of patients treated with the MIS technique. No patients in either group developed hardware failure requiring revision surgery. CONCLUSIONS MIS for MESCC is a safe and effective approach for decompression and stabilization compared with standard open separation surgery, and it significantly reduced blood loss during surgery. Although there was a trend toward a faster time to starting radiation treatment in the MIS group, both groups received similar postoperative radiotherapy doses, with similar rates of local recurrence and hardware failure. An increased ability to perform MIS in emergency settings as well as larger, prospective studies are needed to determine the potential benefits of MIS over standard open separation surgery.
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Affiliation(s)
- Murray Echt
- 1Spine Research Group and.,2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
| | - Ariel Stock
- 1Spine Research Group and.,2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
| | - Rafael De la Garza Ramos
- 1Spine Research Group and.,2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
| | | | - Mousa Hamad
- 1Spine Research Group and.,2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
| | - Ryan Holland
- 1Spine Research Group and.,2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
| | - Phillip Cezayirli
- 1Spine Research Group and.,2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
| | - Rani Nasser
- 3Department of Neurological Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Vijay Yanamadala
- 1Spine Research Group and.,2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
| | - Reza Yassari
- 1Spine Research Group and.,2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
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Li J, Wei W, Xu F, Wang Y, Liu Y, Fu C. Clinical Therapy of Metastatic Spinal Tumors. Front Surg 2021; 8:626873. [PMID: 33937314 PMCID: PMC8084350 DOI: 10.3389/fsurg.2021.626873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 03/23/2021] [Indexed: 11/13/2022] Open
Abstract
Metastatic spinal tumors (MST) have high rates of morbidity and mortality. MST can destroy the vertebral body or compress the nerve roots, resulting in an increased risk of pathological fractures and intractable pain. Here, we elaborately reviewed the currently available therapeutic options for MST according to the following four aspects: surgical management, minimally invasive therapy (MIT), radiation therapy, and systemic therapy. In particular, these aspects were classified and introduced to show their developmental process, clinical effects, advantages, and current limitations. Furthermore, with the improvement of treatment concepts and techniques, we discovered the prevalent trend toward the use of radiation therapy and MIT in clinic therapies. Finally, the future directions of these treatment options were discussed. We hoped that along with future advances and study will lead to the improvement of living standard and present status of treatment in patients with MST.
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Affiliation(s)
- Jie Li
- Department of Spine Surgery, The First Hospital of Jilin University, Changchun, China.,Key Laboratory of Polymer Ecomaterials, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, China
| | - Wenjie Wei
- Key Laboratory of Pathobiology, Ministry of Education, School of Basic Medical Sciences, Jilin University, Changchun, China
| | - Feng Xu
- Department of Spine Surgery, The First Hospital of Jilin University, Changchun, China
| | - Yuanyi Wang
- Department of Spine Surgery, The First Hospital of Jilin University, Changchun, China
| | - Yadong Liu
- Department of Spine Surgery, The First Hospital of Jilin University, Changchun, China
| | - Changfeng Fu
- Department of Spine Surgery, The First Hospital of Jilin University, Changchun, China
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Wagner A, Haag E, Joerger AK, Jost P, Combs SE, Wostrack M, Gempt J, Meyer B. Comprehensive surgical treatment strategy for spinal metastases. Sci Rep 2021; 11:7988. [PMID: 33846484 PMCID: PMC8042046 DOI: 10.1038/s41598-021-87121-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/24/2021] [Indexed: 12/31/2022] Open
Abstract
The management of patients with spinal metastases (SM) requires a multidisciplinary team of specialists involved in oncological care. Surgical management has evolved significantly over the recent years, which warrants reevaluation of its role in the oncological treatment concept. Any patient with a SM was screened for study inclusion. We report baseline characteristics, surgical procedures, complication rates, functional status and outcome of a large consecutive cohort undergoing surgical treatment according to an algorithm. 667 patients underwent 989 surgeries with a mean age of 65 years (min/max 20–94) between 2007 and 2018. The primary cancers mostly originated from the prostate (21.7%), breast (15.9%) and lung (10.0%). Surgical treatment consisted of dorsoventral stabilization in 69.5%, decompression without instrumentation in 12.5% and kyphoplasty in 18.0%. Overall survival reached 18.4 months (95% CI 9.8–26.9) and the median KPS increased by 10 within hospital stay. Surgical management of SMs should generally represent the first step of a conclusive treatment algorithm. The need to preserve long-term symptom control and biomechanical stability requires a surgical strategy currently not supported by level I evidence.
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Affiliation(s)
- Arthur Wagner
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Elena Haag
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany
| | - Ann-Kathrin Joerger
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany
| | - Philipp Jost
- Department of Hematology and Oncology, Technical University Munich School of Medicine, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University Munich School of Medicine, Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany
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Baldassarre BM, Penner F, Bertero L, Di Perna G, Ajello M, Marengo N, Zenga F, Garbossa D. Solitary late spinal metastasis from apocrine salivary duct carcinoma: Case report. Surg Neurol Int 2021; 12:122. [PMID: 33880227 PMCID: PMC8053463 DOI: 10.25259/sni_903_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/19/2021] [Indexed: 11/04/2022] Open
Abstract
Background The salivary duct carcinomas (SDCs) are rare, high-grade neoplasms involving major salivary glands. Parotid is the most frequently involved gland (85%). Apocrine phenotype (histological presence of decapitation secretions) and androgen reception expression define SDC. The clinical course of these tumors is characterized by aggressive local behavior with extraglandular extension, high recurrence rates, early metastases, and poor prognoses. Despite aggressive surgical/radiation therapy management, the rates of locoregional and metastatic relapses are high, and the mortality rates over 48 months approach 65%. Notably, there is no treatment algorithm available for managing vertebral metastases from apocrine SDC. Case Description An elderly male presented with MR/CT findings of an isolated T11 vertebral metastasis attributed to a previously treated parotid SDC. On both CT/MR, it was an osteolytic lesion and demonstrated spinal canal infiltration. The patient underwent surgical biopsy/decompression/resection, following which the lesion histopathologically proved to be a SDC. The patient was subsequently treated with 30 Gy in 10 fractions within 2 weeks of discharge. One-month later, the MRI confirmed adequate epidural decompression without recurrence, and 9 months post-operatively, patient remained disease free. Conclusion Isolated metastasis attributed to parotid SDC followed by radiation therapy may result in tumor control.
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Affiliation(s)
| | - Federica Penner
- Department of Neuroscience, Neurosurgery Unit, Città Della Scienza e Della Salute, Italy
| | - Luca Bertero
- Department of Pathologic, Città Della Scienza e Della Salute, Turin, Italy
| | - Giuseppe Di Perna
- Department of Neuroscience, Neurosurgery Unit, Città Della Scienza e Della Salute, Italy
| | - Marco Ajello
- Department of Neuroscience, Neurosurgery Unit, Città Della Scienza e Della Salute, Italy
| | - Nicola Marengo
- Department of Neuroscience, Neurosurgery Unit, Città Della Scienza e Della Salute, Italy
| | - Francesco Zenga
- Department of Neuroscience, Neurosurgery Unit, Città Della Scienza e Della Salute, Italy
| | - Diego Garbossa
- Department of Neuroscience, Neurosurgery Unit, Città Della Scienza e Della Salute, Italy
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Management Challenges of Metastatic Spinal Cord Compression in Pregnancy. Case Rep Surg 2020; 2020:8891021. [PMID: 33204568 PMCID: PMC7652620 DOI: 10.1155/2020/8891021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 10/13/2020] [Accepted: 10/24/2020] [Indexed: 11/17/2022] Open
Abstract
Primary and secondary spinal tumours with cord compression often represent a challenging condition for the patient and clinicians alike, even more so during pregnancy. The balance between safe delivery of a healthy baby and management of the mother's disease bears many clinical, psychological, and ethical dilemmas. Pregnancy sets a conflict between the optimal surgical and oncological managements of the mother's tumour and the well-being of her foetus. We followed the CARE guidelines from the EQUATOR Network to report an exemplificative case of a 39-year-old woman with a 10-year history of breast cancer, presenting in the second trimester of her first pregnancy with acute onset severe thoracic spinal instability, causing mechanical pain and weakness in lower limbs. Neuroradiological investigations revealed multilevel spinal deposits with a pathological T10 fracture responsible for spinal cord compression. The patient was adamant that she wanted a continuation of the pregnancy and her baby delivered. After discussion with her oncologist and obstetrician, we agreed to perform emergency spinal surgery—decompression and instrumented fixation. The literature search did not reveal a similar case of spinal metastatic breast cancer undergoing spinal instrumentation and delivery of a healthy baby a few months later. Following the delivery, the patient had further oncological treatment, including chemotherapy and radiotherapy. The paucity of such reports prompted us to present this case and highlight the relevance of a multidisciplinary approach involving obstetrician, oncologist, spinal surgeon, and radiologist to guide the optimal decision-making process.
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Cofano F, Di Perna G, Alberti A, Baldassarre BM, Ajello M, Marengo N, Tartara F, Zenga F, Garbossa D. Neurological outcomes after surgery for spinal metastases in symptomatic patients: Does the type of decompression play a role? A comparison between different strategies in a 10-year experience. J Bone Oncol 2020; 26:100340. [PMID: 33294319 PMCID: PMC7689400 DOI: 10.1016/j.jbo.2020.100340] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 10/30/2020] [Accepted: 11/02/2020] [Indexed: 12/27/2022] Open
Abstract
The achievement of a proper circumferential decompression of the sac instead of simple posterior bilateral laminectomy has been progressively highlighted. Since the majority of spinal cord compression involves firstly the ventral part of the sac, circumferential and anterior decompression are associated with better neurological outcomes at discharge and at follow-up, and should be achieved in case of circumferential or anterior/anterolateral compression. Post-operative improvement and/or maintenance of ambulation resulted to be a significative protective factor at last follow-up.
Introduction The impact of neurological deficits plays a role of inestimable importance in patients with a neoplastic disease. The role of surgery for the management of symptomatic spinal cord compression (SSCC) cannot be overemphasized, as surgery represents often the first and paramount step in patients presenting with motor deficits. The traditional paradigm of simple bilateral laminectomy for the treatment of spinal cord compression has been reviewed. The need to achieve a proper circumferential decompression of the spinal sac has been progressively highlighted in combination with the development of the more comprehensive and multidisciplinary concept of separation surgery. Objective The aim of this paper is to analyze different strategies of decompression, while evaluating whether circumferential/anterior decompression is able to guarantee a better control and restoration of neurological functions in patients with motor impairment, if compared to traditional posterior decompression. Materials and methods This is a retrospective observational study investigating symptomatic patients that underwent surgical treatment for spinal metastases at author’s Institutions from January 2010 to June 2019. Data recorded concerned patient demographics, tumor histology, peri-operative and follow-up neurological status (ASIA), ambulation ability, stability (SINS), grade (ESCC) and source of epidural compression and type of decompression (anterior/anterior-lateral (AD); posterior/posterior-lateral (PD/PDL); circumferential (CD)). Results A total number of 84 patients was included. AD/CD patients showed higher chance of neurological improvement and reduced rates of worsening compared to PD/PLD group (94.1%/100% vs 60.4%; 11.8% vs 45.8% respectively). Univariate logistic regression identified immediate post-operative improvement to be a significative protective factor for worsening at last follow-up. Stratifying patients for site of compression and considering anterior and circumferential groups, immediate post-operative neurological improvement, was mostly associated with AD and CD (p 0.011 and 0.025 respectively). Walking at last follow up was influenced by post-operative maintenance of ambulation (p 0.001). Conclusion The necessity to remove the epidural metastatic compression from its source should be considered of paramount importance. Since the majority of spinal cord compression involves firstly the ventral part of the sac, CD/AD are associated with better neurological outcomes and should be achieved in case of circumferential or anterior/anterolateral compression.
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Key Words
- A-lSCC, antero-lateral spinal cord compression
- AD, anterior decompression
- ASCC, anterior spinal cord compression
- ASIA, American Spinal Injury Association Impairment Scale
- CD, circumferential decompression
- CSCC, circumferential spinal cord compression
- Circumferential decompression
- ESCC, epidural spinal cord compression scale
- HRQoL, health-related quality of life
- IONM, intraoperative neurophysiological monitoring
- MIS, minimally invasive surgical
- Metastatic epidural compression
- Minimal invasive spine surgery
- P-lSCC, postero-lateral spinal cord compression
- PD, posterior decompression
- PLD, postero-lateral decompression
- PSCC, posterior spinal cord compression
- RT, radiotherapy
- SINS, spinal instability neoplastic score
- SSCC, symptomatic spinal cord compression
- Separation surgery
- Spinal metastases
- cEBRT, conventional external beam radiation therapy
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Affiliation(s)
- F Cofano
- Unit of Neurosurgery - Department of Neuroscience, University of Turin, Turin, IT, Italy.,Spine Surgery Unit, Humanitas Gradenigo Hospital, Turin, Italy
| | - G Di Perna
- Unit of Neurosurgery - Department of Neuroscience, University of Turin, Turin, IT, Italy
| | | | - B M Baldassarre
- Unit of Neurosurgery - Department of Neuroscience, University of Turin, Turin, IT, Italy
| | - M Ajello
- Unit of Neurosurgery - Department of Neuroscience, University of Turin, Turin, IT, Italy
| | - N Marengo
- Unit of Neurosurgery - Department of Neuroscience, University of Turin, Turin, IT, Italy
| | - F Tartara
- Unit of Neurosurgery, ICCS Città Studi, Milan, IT, Italy
| | - F Zenga
- Unit of Neurosurgery - Department of Neuroscience, University of Turin, Turin, IT, Italy
| | - D Garbossa
- Unit of Neurosurgery - Department of Neuroscience, University of Turin, Turin, IT, Italy
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