Solitary vertebral metastasis

Massive Spondylectomy for Metastatic Spinal Cord Compression From Non-Small-Cell Lung Cancer With Local Failure After Radiotherapy

STUDY DESIGN.

A retrospective multivariate analysis.

OBJECTIVE.

To analyze clinical outcomes of surgical treatment and prognostic factors of local failure after stereotactic body radiation therapy (SBRT) in patients with spinal metastatic non-small-cell lung cancer (NSCLC).

METHODS.

This study included patients with metastatic spinal cord compression (MSCC) from spinal NSCLC after radiotherapy who received massive spondylectomy for circumferential decompression of spinal cord and reconstruction of spinal stability in our center between May 2006 and February 2017. Neurological function was evaluated using the Frankel score. Overall survival (OS) was estimated by the Kaplan-Meier method. Factors with Pvalues ≤.1 were subjected to multivariate analysis for OS by proportional hazard analysis. Values of P<.05 were considered statistically significant.

RESULTS.

The mean age of the 55 included patients (36 male and 19 female) was 57.76 ± 8.94 (median 58, range 36-77) years, with a mean postoperative OS of 14.98 ± 14.81 (median 10.0, range 1-84) months. Neurological function was improved in 46 (83.6%) of the 55 patients after surgery. Prognostic analysis suggested that preoperative frankel score (FS) score, visceral metastasis, D-dimer (D-D) level, and neutrophil/lymphocyte ratio (NLR) were independent prognostic factors for selected patients.

CONCLUSIONS.

Massive spondylectomy could provide circumferential decompression and improve the neurological function of patients with MSCC from spinal NSCLC after radiotherapy. A preoperative FS score of C/D, no visceral metastasis, D-D <1000 μg/L, and NLR <5 are predictors of better prognosis.

En Bloc Resection of Isolated Spinal Metastasis: A Systematic Review Update

STUDY DESIGN

This work was a systematic review.

OBJECTIVE

The objective of this work was to review the literature on the outcomes of en bloc resection of isolated spinal metastasis.

SUMMARY

Of background data: En bloc resection of isolated spinal metastasis is rarely performed and its utility debated, with the last review of the literature being performed over a decade ago. With significant advances in adjunctive oncology treatments, an updated review of whether there remains a role for this type of surgery is necessary.

METHODS

The authors performed a systematic review of English literature over the last decade on en bloc resection of isolated spinal metastasis in adults using the PubMed, Google Scholar, OVID, and Cochrane database. They excluded studies with <5 reported cases. The studies were appraised by 2 coauthors and examined for the patient and tumor characteristics, surgical time, estimated blood loss, length of hospital stay, cost, complications, functional outcomes, rates of local recurrence, metastasis, and survival.

RESULTS

Only 5 articles (148 patients) were included in this study. The average operative time was 6.5 hours, and estimated blood loss was 1742 mL. Only 73% of patients maintained their functional independence, but 35.1% experienced a complication, 6.1% had local recurrence, and the overall survival was 52% with an average time to death of 15 months.

CONCLUSIONS

There remains a paucity of data limiting the understanding of the value of en bloc resection for isolated spinal metastasis. However, despite this limitation, our literature review suggests that en bloc resection offers a low local recurrence rate (6.1%) and maintained functional independence (73%), but requires long operative times (mean 6.5 h), causes significant blood loss (mean 1742 mL), and results in high complication rates (35.1%) with poor overall survival (52% with an average time to death of 15 mo).

Survival, local control, and health-related quality of life in patients with oligometastatic and polymetastatic spinal tumors: A multicenter, international study

BACKGROUND

The treatment of oligometastatic (≤5 metastases) spinal disease has trended toward ablative therapies, yet to the authors' knowledge little is known regarding the prognosis of patients presenting with oligometastatic spinal disease and the value of this approach. The objective of the current study was to compare the survival and clinical outcomes of patients with cancer with oligometastatic spinal disease with those of patients with polymetastatic (>5 metastases) disease.

METHODS

The current study was an international, multicenter, prospective study. Patients who were admitted to a participating spine center with a diagnosis of spinal metastases and who underwent surgical intervention and/or radiotherapy between August 2013 and May 2017 were included. Data collected included demographics, overall survival, local control, and treatment information including surgical, radiotherapy, and systemic therapy details. Health-related quality of life (HRQOL) measures included the EuroQOL 5 dimensions 3-level questionnaire (EQ-5D-3L), the 36-Item Short Form Health Survey (SF-36v2), and the Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ).

RESULTS

Of the 393 patients included in the current study, 215 presented with oligometastatic disease and 178 presented with polymetastatic disease. A significant survival advantage of 90.1% versus 77.3% at 3 months and 77.0% versus 65.1% at 6 months from the time of treatment was found for patients presenting with oligometastatic disease compared with those with polymetastatic disease. It is important to note that both groups experienced significant improvements in multiple HRQOL measures at 6 months after treatment, with no differences in these outcome measures noted between the 2 groups.

CONCLUSIONS

The treatment of oligometastatic disease appears to offer a significant survival advantage compared with polymetastatic disease, regardless of treatment choice. HRQOL measures were found to improve in both groups, demonstrating a palliative benefit for all treated patients.

Prognostic Factors of Surgical Complications and Overall Survival of Patients with Metastatic Spinal Tumor

OBJECTIVE

Oncologic treatments increase the incidence of spinal metastases. Surgical treatment of spinal metastases results in a high complication rate, which must set against the expected benefits. The aim of this article was to study the effect of several prognostic factors on surgical complications and survival time using an extended database of patients with spinal metastases.

METHODS

This retrospective study comprised 337 patients with spinal metastases who were surgically treated between 2008 and 2015. Demographic and clinical features, oncologic histories, surgical interventions, and end results were collected. Descriptive statistical methods were used to analyze the cohort of patients. Kaplan-Meier formula and log-rank test were used to examine overall survival times.

RESULTS

Median overall survival time was 222 days (range, 175-274 days). Age, preoperative motor disorders, preoperative Frankel grade categories, Karnofsky performance scale, type of primary tumor, and presence of internal metastasis had a significant negative effect on overall survival. Complications such as bleeding or need for intensive care could be predicted preoperatively based on preoperative performance status, type of primary tumor, affected vertebral levels, and type of surgical interventions.

CONCLUSIONS

Spinal metastatic disease is a challenging surgical problem. If the exact prognostic factors are known preoperatively, surgical outcome and overall survival can be predicted more precisely. Our results could provide a basis for a future multicenter prospective study to determine the best treatment protocol for patients with spinal metastases.

Use of C2 vertebroplasty and stereotactic radiosurgery for treatment of lytic metastasis of the odontoid process

Improvements in cancer therapy have led to increased patient survival times in spite of metastatic spinal disease in many forms of cancer. Conventional treatment methods often employ radiotherapy with or without surgery depending on the neurological status, mechanical instability, and the extent of tumor. Percutaneous vertebroplasty as well as stereotactic radiosurgery (SRS) have arisen as common modalities of treatment of spinal metastasis in which neurological compromise or spinal instability and deformity is not of significant concern. These treatments, when used in combination, have been shown to provide early pain relief and effective tumor control while avoiding surgical resection, fixation, and lengthy recovery times. We present a case unique in the literature for the use of this combination treatment for tumors of the C2 vertebral body. While limited in application to patients without overt atlantoaxial instability or significant spinal canal compromise, we believe it provides a significant benefit in decreasing morbidity and improving early adherence to systemic therapy.

Prognostic Factors and Comparison of Conservative Treatment, Percutaneous Vertebroplasty, and Open Surgery in the Treatment of Spinal Metastases from Lung Cancer

BACKGROUND

Spinal metastases from lung cancer could result in life-threatening consequences. Few studies report the prognostic factors and compare different treatments in patients with spinal metastases from lung cancer.

METHODS

From 2005 to 2014, we retrospectively reviewed and studied 140 patients with spinal metastases from lung cancer according to different treatments. To estimate overall survival and identify prognostic factors for survival, the Kaplan-Meier method and Cox regression analysis were adopted. In addition, the Kaplan-Meier method was used to compare different treatments for overall survival.

RESULTS

All patients in a conservative group and a percutaneous vertebroplasty group died at a median survival time of 7 months for both groups. As for patients in the open-surgery group, 42 patients died at a median of 11 months, and 7 patients who were still alive at the time of this study were followed for a median of 29 months. Multivariate analysis suggested that better survival was significantly associated with American Spinal Injury Association grade D/E on admission, American Spinal Injury Association grade E after surgery, Eastern Cooperative Oncology Group performance status 1-2, and adjuvant radiation therapy in all 3 groups. In addition, Kaplan-Meier analysis showed that the overall survival rate of the open-surgery group (14.3%) was better than that of conservative group (0%) and the percutaneous vertebroplasty group (0%).

CONCLUSIONS

A better overall survival outcome might be achieved by a series of comprehensive and individualized treatments and personalized treatment.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Timely stereotactic body radiotherapy (SBRT) for spine metastases using a rapidly deployable automated planning algorithm

Purpose/objectives

The complex planning and quality assurance required for spine SBRT are a barrier to implementation in time-sensitive or limited resource clinical situations. We developed and validated an automated inverse planning algorithm designed to streamline planning and allow rapid delivery of conformal single fraction spine SBRT using widely available technology.

Materials/methods

The Rapid Spine (RaSp) automated script successfully generated single fraction SBRT plans for fourteen complex spinal lesions previously treated at a single high-volume institution. Automated RaSp plans were limited to 5 beams with a total of 15 segments (allowing calculation-based verification) and optimized based on RTOG 0631 objectives. Standard single fraction (16 Gy) stereotactic IMRT plans were generated for the same set of complex spinal lesions and used for comparison. A conservative 2 mm posterior isocenter shift was used to simulate minor set-up error.

Results

Automated plans were generated in under 5 min from target definition and had a mean dose to the PTV of 1663 cGy (SD 131.5), a dose to 90 % of PTV (D90) of 1358 cGy (SD 111.0), and a maximum point dose (Dmax) to the PTV of 2055 cGy (SD 195.2) on average. IMRT plans took longer to generate but yielded more favorable dose escalation with a mean dose to the PTV of 1891 cGy (SD 117.6), D90 of 1731 cGy (SD 126.5), and Dmax of 2218 cGy (SD 195.7). A 2 mm posterior shift resulted in a 20 % (SD 10.5 %) increase in cord dose for IMRT plans and a 10 % (SD 5.3 %) increase for RaSp plans. The 2 mm perturbation caused 3 cord dose violations for the IMRT plans and 1 violation for corresponding RaSp plans.

Conclusion

The Rapid Spine plan method yields timely and dosimetrically reasonable SBRT plans which meet RTOG 0631 objectives and are suitable for rapid yet robust pretreatment quality assurance followed by expedited treatment delivery. RaSp plans reduce the tradeoff between rapid treatment and optimal dosimetry in urgent cases and limited resource situations.

En Bloc Resection of Solitary Functional Secreting Spinal Metastasis

Study Design Literature review. Objective Functional secretory tumors metastatic to the spine can secrete hormones, growth factors, peptides, and/or molecules into the systemic circulation that cause distinct syndromes, clinically symptomatic effects, and/or additional morbidity and mortality. En bloc resection has a limited role in metastatic spine disease due to the current paradigm that systemic burden usually determines morbidity and mortality. Our objective is to review the literature for studies focused on en bloc resection of functionally active spinal metastasis as the primary indication. Methods A review of the PubMed literature was performed to identify studies focused on functional secreting metastatic tumors to the spinal column. We identified five cases of patients undergoing en bloc resection of spinal metastases from functional secreting tumors. Results The primary histologies of these spinal metastases were pheochromocytoma, carcinoid tumor, choriocarcinoma, and a fibroblast growth factor 23-secreting phosphaturic mesenchymal tumor. Although studies of en bloc resection for these rare tumor subtypes are confined to case reports, this surgical treatment option resulted in metabolic cures and decreased clinical symptoms postoperatively for patients diagnosed with solitary functional secretory spinal metastasis. Conclusion Although the ability to formulate comprehensive conclusions is limited, case reports demonstrate that en bloc resection may be considered as a potential surgical option for the treatment of patients diagnosed with solitary functional secretory spinal metastatic tumors. Future prospective investigations into clinical outcomes should be conducted comparing intralesional resection and en bloc resection for patients diagnosed with solitary functional secretory spinal metastasis.

Effect of Surgery on Quality of Life of Patients with Spinal Metastasis from Non-Small-Cell Lung Cancer

BACKGROUND

Recently, more clinicians have realized the importance of quality of life in the treatment decision-making process. The goal of this study was to determine whether surgery for patients with spinal metastases from non-small-cell lung cancer (NSCLC) could improve their quality of life and prolong survival.

METHODS

The study included 133 patients who had been treated for NSCLC spinal metastases between 2010 and 2014. These patients were divided into two groups according to whether or not they had received spinal surgery. Their quality of life was assessed with use of the Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire at the initial diagnosis (baseline) and at one, three, six, and nine months after the diagnosis. The survival times of all patients were also collected.

RESULTS

Of the 133 patients, eighty-six (forty-five in the surgery group and forty-one in the non-surgery group) survived for nine months and were assessed at all of the follow-up intervals. The surgery group had significantly higher total, physical well-being, emotional well-being, and functional well-being quality-of-life scores at each follow-up time point as compared with baseline (p < 0.001) as well as compared with the non-surgery group (p < 0.001). A log-rank test demonstrated that the surgery group had longer survival than the non-surgery group (p = 0.020).

CONCLUSIONS

The results of this study indicate that surgical treatment improved the quality of life of patients with NSCLC spinal metastases over the nine-month assessment period. The surgery group had a better quality of life and longer survival than the non-surgery group.

Metastatic Spinal Cord Compression from Non-Small-Cell Lung Cancer Treated with Surgery and Adjuvant Therapies: A Retrospective Analysis of Outcomes and Prognostic Factors in 116 Patients

BACKGROUND

Metastatic spinal cord compression is a disastrous consequence of non-small-cell lung cancer (NSCLC). There have been few studies of the outcomes or prognostic factors in patients with metastatic spinal cord compression from NSCLC treated with surgery and adjuvant therapies.

METHODS

From 2002 to 2013, 116 patients with metastatic spinal cord compression from NSCLC treated with surgery and adjuvant therapies were enrolled in this retrospective analysis. Kaplan-Meier methods and Cox regression analysis were used to estimate overall survival and identify prognostic factors for survival.

RESULTS

Multivariate analysis suggested that the Eastern Cooperative Oncology Group performance status (ECOG-PS), preoperative and postoperative Frankel scores, postoperative adjuvant radiation therapy, and target therapy were independent prognostic factors. Ninety patients died at a median of twelve months (range, three to forty-seven months) postoperatively, and twenty-six patients were still alive at the time of final follow-up (at a median of fifteen months [range, five to fifty-four months]).

CONCLUSIONS

The complete disappearance of deficits in spinal cord function after surgery was the most robust predictor of survival. Adjuvant radiation therapy and target therapy were also associated with a better prognosis.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

XCR1 promotes cell growth and migration and is correlated with bone metastasis in non-small cell lung cancer

Bone metastasis occurs in approximately 30-40% patients with advanced non-small cell lung cancer (NSCLC), but the mechanism underlying this bone metastasis remains poorly understood. The chemokine super family is believed to play an important role in tumor metastasis in lung cancer. The chemokine receptor XCR1 has been identified to promote cell proliferation and migration in oral cancer and ovarian carcinoma, but the role of XCR1 in lung cancer has not been reported. In this study, we demonstrated for the first time that XCR1 was overexpressed in lung cancer bone metastasis as compared with that in patients with primary lung cancer. In addition, the XCR1 ligand XCL1 promoted the proliferation and migration of lung cancer cells markedly, and knockdown of XCR1 by siRNA abolished the effect of XCL1 in cell proliferation and migration. Furthermore, we identified JAK2/STAT3 as a novel downstream pathway of XCR1, while XCL1/XCR1 increased the mRNA level of the downstream of JAK2/STAT3 including PIM1, JunB, TTP, MMP2 and MMP9. These results indicate that XCR1 is a new potential therapeutic target for the treatment of lung cancer bone metastasis.

Commentary: Spinal instrumentation for mechanical radiculopathy secondary to lumbar metastases

Moliterno J, Veselis CA, Hershey MA, et al. Improvement in pain after lumbar surgery in cancer patients with mechanical radiculopathy. Spine J 2014;14:2434-9 (in this issue).

The management of pain in metastatic bone disease

BACKGROUND

Metastatic bone disease is a common cause of pain in cancer patients. A multidisciplinary approach to treatment is often necessary because simplified analgesic regimens may fail in the face of complex pain generators, especially those involved in the genesis of neuropathic pain. From the origins of formalized guidelines by the World Health Organization (WHO) to recent developments in implantable therapies, great strides have been made to meet the needs of these patients.

METHODS

The authors review the existing literature on the pathophysiology and treatment options for pain generated by metastatic bone disease and summarize classic and new approaches.

RESULTS

Relatively recent animal models of malignant bone disease have allowed a better understanding of the intimate mechanisms involved in the genesis of pain, resulting in a mechanistic approach to its treatment. Analgesic strategies can be developed with specific targets in mind to complement the classic, opioid-centered WHO analgesic ladder obtaining improved outcomes and quality of life. Unfortunately, high-quality evidence is difficult to produce in pain medicine, and these concepts are evolving slowly.

CONCLUSIONS

Treatment options are expanding for the challenging clinical problem of painful metastatic bone disease. Efforts are concentrated on developing alternative nonopioid approaches that appear to increase the success rate and improve patients' quality of life.

Radioactive bone cement for the treatment of spinal metastases: a dosimetric analysis of simulated clinical scenarios

Vertebral metastases are a common manifestation of many cancers, potentially leading to vertebral collapse and neurological complications. Conventional treatment often involves percutaneous vertebroplasty/kyphoplasty followed by external beam radiation therapy. As a more convenient alternative, we have introduced radioactive bone cement, i.e. bone cement incorporating a radionuclide. In this study, we used a previously developed Monte Carlo radiation transport modeling method to evaluate dose distributions from phosphorus-32 radioactive cement in simulated clinical scenarios. Isodose curves were generally concentric about the surface of bone cement injected into cadaveric vertebrae, indicating that dose distributions are relatively predictable, thus facilitating treatment planning (cement formulation and dosimetry method are patent pending). Model results indicated that a therapeutic dose could be delivered to tumor/bone within ∼4 mm of the cement surface while maintaining a safe dose to radiosensitive tissue beyond this distance. This therapeutic range should be sufficient to treat target volumes within the vertebral body when tumor ablation or other techniques are used to create a cavity into which the radioactive cement can be injected. With further development, treating spinal metastases with radioactive bone cement may become a clinically useful and convenient alternative to the conventional two-step approach of percutaneous strength restoration followed by radiotherapy.

Kyphoplasty for lytic tumour lesions of the spine: prospective follow-up of 11 cases from procedure to death

BACKGROUND

The life span of cancer patients has improved due to advancements in cancer management. With long survival periods, more patients show metastatic disease. Osteolytic tumours of spine are generated by metastatic deposits or primary tumours of the spine. A prospective study was performed to evaluate the efficacy and safety of percutaneous kyphoplasty in patients with osteolytic tumours of the thoracic and lumbar spine.

MATERIALS AND METHODS

Eleven patients (age range 52-77/average 65 years; 7 female, 4 male) with osteolytic tumours of the spine were treated with kyphoplasty. The main Tokuhashi score was registered preoperatively. Outcome was assessed prospectively by visual analogue scale (VAS) for pain, ECOG performance status, walking distance, standing and sitting time.

RESULTS

Preoperative VAS (average 7.5; range 2.6-10) dropped to 3.0, 5 days postoperatively and remained below 5 for follow-up. Main Tokuhashi score was 6.3, ranging from 3 to 9. Survival time ranged from 2 to 293 (average 74.4) weeks. Average walking distance, standing and sitting time and ECOG performance score showed improvement. All patients returned home and no patient required re-operation or readmission due to local disease progression or recurrence.

CONCLUSION

Kyphoplasty is a suitable palliative treatment option for patients with advanced metastatic disease of the spine even with low Tokuhashi scores allowing rapid pain relief and mobilisation to increase the quality of life.

Kypho-IORT--a novel approach of intraoperative radiotherapy during kyphoplasty for vertebral metastases

BACKGROUND

Instable and painful vertebral metastases in patients with progressive visceral metastases present a common therapeutic dilemma. We developed a novel approach to deliver intraoperative radiotherapy (IORT) during kyphoplasty and report the first treated case.

METHODS/RESULTS

60 year old patient with metastasizing breast cancer under chemotherapy presented with a newly diagnosed painful metastasis in the 12th thoracic vertebra. Under general anaesthesia, a bipedicular approach into the vertebra was chosen with insertion of specially designed metallic sleeves to guide the electron drift tube of the miniature X-ray generator (INTRABEAM, Carl Zeiss Surgical, Oberkochen, Germany). This was inserted with a novel sheet designed for this approach protecting the drift tube. A radiation dose of 8 Gy in 5 mm distance (50 kV X-rays) was delivered. The kyphoplasty balloons (KyphX, Kyphon Inc, Sunnyvale) were inflated after IORT and polymethylmethacrylate cement was injected. The whole procedure lasted less than 90 minutes.

CONCLUSION

In conclusion, this novel, minimally invasive procedure can be performed in standard operating rooms and may become a valuable option for patients with vertebral metastases providing immediate stability and local control. A phase I/II study is under way to establish the optimal dose prescription.

Stereotactic radiosurgery for spinal metastases: case report and review of treatment options

The spine is the most common site for bone metastases. Spinal metastases can impact quality of life by causing severe pain, limitation of motion, and increased requirements for pain medication. Radiation therapy is a common form of treatment reserved for palliation of pain and for prevention or treatment of spinal cord compression. Newer approaches such as stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) have a more precise ability to customize the radiation dose to the target tissues adjacent to critical structures, thus increasing the local control of spinal column metastases. In this report, we examine the efficacy and possible advantages of single fraction SRS using a state-of-the-art tomotherapy machine in the treatment of a patient with spinal metastases from breast cancer. We also review the literature on treatment of spinal metastases using SRS, SBRT, and other modalities.