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Hussain I, Goldberg JL, Carnevale JA, Hanz SZ, Reiner AS, Schmitt A, Higginson DS, Yamada Y, Laufer I, Bilsky MH, Barzilai O. Hybrid Therapy (Surgery and Radiosurgery) for the Treatment of Renal Cell Carcinoma Spinal Metastases. Neurosurgery 2022; 90:199-206. [PMID: 35023875 PMCID: PMC9508965 DOI: 10.1227/neu.0000000000001780] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 09/01/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The management of spinal metastatic renal cell carcinoma (mRCC) is controversial regarding extent of resection and radiation dosing. OBJECTIVE To determine outcomes in patients treated with hybrid therapy (separation surgery plus adjuvant stereotactic body radiation therapy [SBRT]) for mRCC. METHODS A retrospective study of a prospectively collected cohort of patients undergoing hybrid therapy for mRCC between 2003 and 2017 was performed. SBRT was delivered as high-dose single-fraction, high-dose hypofractionated, or low-dose hypofractionated. Extent of disease, clinical and operative outcomes, and complications data were collected, and associations with overall survival (OS) and progression-free survival were determined. RESULTS Ninety patients with mRCC with high-grade epidural spinal cord compression (ESCC grades 2 and 3) were treated. Metastases were widespread, oligometastatic, and solitary in 56%, 33%, and 11% of patients, respectively. SBRT delivered was high-dose single-fraction, high-dose hypofractionated, and low-dose hypofractionated in 24%, 56%, and 20% of patients, respectively. The 1-yr cumulative incidence of major complications was 3.4% (95% confidence interval [CI]: 0.0%-7.2%). The median follow-up was 14.2 mo for the entire cohort and 38.3 mo for survivors. The 1-yr cumulative incidence of progression was 4.6% (95% CI: 0.2%-9.0%), which translates to a local control rate of 95.4% (95% CI: 91.0%-99.8%) 1 yr after surgery. The median OS for the cohort was 14.8 mo. CONCLUSION These data support the use of hybrid therapy as a safe and effective strategy for the treatment of renal cell spine metastases.
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Affiliation(s)
- Ibrahim Hussain
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA;
- Department of Neurological Surgery, Weill Cornell Medical College, New York, New York, USA;
| | - Jacob L. Goldberg
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA;
- Department of Neurological Surgery, Weill Cornell Medical College, New York, New York, USA;
| | - Joseph A. Carnevale
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA;
- Department of Neurological Surgery, Weill Cornell Medical College, New York, New York, USA;
| | - Samuel Z. Hanz
- Department of Neurological Surgery, Weill Cornell Medical College, New York, New York, USA;
| | - Anne S. Reiner
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA;
| | - Adam Schmitt
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Daniel S. Higginson
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ilya Laufer
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA;
- Department of Neurological Surgery, Weill Cornell Medical College, New York, New York, USA;
| | - Mark H. Bilsky
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA;
- Department of Neurological Surgery, Weill Cornell Medical College, New York, New York, USA;
| | - Ori Barzilai
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA;
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Li RF, Qiao RQ, Xu MY, Ma RX, Hu YC. Separation Surgery in the Treatment of Spinal Metastasis. Technol Cancer Res Treat 2022; 21:15330338221107208. [PMID: 35702739 PMCID: PMC9208034 DOI: 10.1177/15330338221107208] [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] [Indexed: 11/24/2022] Open
Abstract
The life expectancy of patients with advanced cancer has been prolonged with the development of systemic treatment technology. Spinal metastasis is one of the common ways of metastasis of advanced tumors, leading to spinal cord compression and compression fractures, which often lead to a significant reduction in patients’ quality of life and physical function. Therefore, surgical treatment is still needed for functional recovery and local control. Separation surgery has been known since 2014 when it was purposed. Combined with radiotherapy, it can achieve an ideal goal of local control. This paper gives a brief introduction to separation surgery, hoping to increase the reader's understanding and consider this method in the course of treatment.
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Affiliation(s)
- Rui-Feng Li
- Department of Bone and Soft Tissue Oncology, 74768Tianjin Hospital, Tianjin, China.,Graduate School, 12610Tianjin Medical University, Tianjin, China
| | - Rui-Qi Qiao
- Department of Bone and Soft Tissue Oncology, 74768Tianjin Hospital, Tianjin, China.,Graduate School, 12610Tianjin Medical University, Tianjin, China
| | - Ming-You Xu
- Department of Bone and Soft Tissue Oncology, 74768Tianjin Hospital, Tianjin, China.,Graduate School, 12610Tianjin Medical University, Tianjin, China
| | - Rong-Xing Ma
- Department of Bone and Soft Tissue Oncology, 74768Tianjin Hospital, Tianjin, China.,Graduate School, 12610Tianjin Medical University, Tianjin, China
| | - Yong-Cheng Hu
- Department of Bone and Soft Tissue Oncology, 74768Tianjin Hospital, Tianjin, China
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Yevich S, Chen S, Metwalli Z, Kuban J, Lee S, Habibollahi P, McCarthy CJ, Irwin D, Huang S, Sheth RA. Radiofrequency Ablation of Spine Metastases: A Clinical and Technical Approach. Semin Musculoskelet Radiol 2021; 25:795-804. [PMID: 34937119 DOI: 10.1055/s-0041-1740351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Percutaneous radiofrequency ablation (RFA) is an integral component of the multidisciplinary treatment algorithm for both local tumor control and palliation of painful spine metastases. This minimally invasive therapy complements additional treatment strategies, such as pain medications, systemic chemotherapy, surgical resection, and radiotherapy. The location and size of the metastatic lesion dictate preprocedure planning and the technical approach. For example, ablation of lesions along the spinal canal, within the posterior vertebral elements, or with paraspinal soft tissue extension are associated with a higher risk of injury to adjacent spinal nerves. Additional interventions may be indicated in conjunction with RFA. For example, ablation of vertebral body lesions can precipitate new, or exacerbate existing, pathologic vertebral compression fractures that can be prevented with vertebral augmentation. This article reviews the indications, clinical work-up, and technical approach for RFA of spine metastases.
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Affiliation(s)
- Steven Yevich
- Division of Diagnostic Imaging, Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephen Chen
- Division of Diagnostic Imaging, Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zeyad Metwalli
- Division of Diagnostic Imaging, Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joshua Kuban
- Division of Diagnostic Imaging, Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephen Lee
- Division of Diagnostic Imaging, Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Peiman Habibollahi
- Division of Diagnostic Imaging, Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Colin J McCarthy
- Division of Diagnostic Imaging, Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David Irwin
- Division of Diagnostic Imaging, Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steven Huang
- Division of Diagnostic Imaging, Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rahul A Sheth
- Division of Diagnostic Imaging, Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Nieblas-Bedolla E, Zuccato J, Kluger H, Zadeh G, Brastianos PK. Central Nervous System Metastases. Hematol Oncol Clin North Am 2021; 36:161-188. [PMID: 34711458 DOI: 10.1016/j.hoc.2021.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The proportion of patients developing central nervous system (CNS) metastasis is increasing. Most are identified once symptomatic. Surgical resection is indicated for solitary or symptomatic brain metastases, separation surgery for compressive radioresistant spinal metastases, and instrumentation for unstable spinal lesions. Surgical biopsies are performed when histological diagnoses are required. Stereotactic radiosurgery is an option for limited small brain metastases and radioresistant spinal metastases. Whole-brain radiotherapy is reserved for extensive brain metastases and leptomeningeal disease with approaches to reduce cognitive side effects. Radiosensitive and inoperable spinal metastases typically receive external beam radiotherapy. Systemic therapy is increasingly being utilized for CNS metastases.
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Affiliation(s)
- Edwin Nieblas-Bedolla
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Jeffrey Zuccato
- MacFeeters-Hamilton Center for Neuro-Oncology Research, Princess Margaret Cancer Center, 14-701, Toronto Medical Discovery Tower (TMDT), 101 College Street, Toronto, Ontario M5G 1L7, Canada
| | - Harriet Kluger
- Section of Medical Oncology-WWW211, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520, USA
| | - Gelareh Zadeh
- MacFeeters-Hamilton Center for Neuro-Oncology Research, Princess Margaret Cancer Center, 14-701, Toronto Medical Discovery Tower (TMDT), 101 College Street, Toronto, Ontario M5G 1L7, Canada.
| | - Priscilla K Brastianos
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
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Meleis A, Larkin MB, Bastos DCDA, Muir MT, Rao G, Rhines LD, Cowles CE, Tatsui CE. Single-center outcomes for percutaneous pedicle screw fixation in metastatic spinal lesions: can spontaneous facet fusion occur? Neurosurg Focus 2021; 50:E9. [PMID: 33932939 DOI: 10.3171/2021.1.focus20671] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 01/08/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Survival of cancer patients continues to improve with systemic treatment advancements, leading to an increase in cancer-related complications such as pathological spinal fractures. In this study, the authors aimed to evaluate the outcome of percutaneous stabilization with cement augmentation of the pedicle screws in the management of patients with metastatic cancer to the spine. METHODS The authors reviewed a retrospective case series of 74 patients with symptomatic pathological spine fractures treated with cement-augmented pedicle screws implanted with a percutaneous technique. The mean imaging follow-up was 11.3 months. Data on demographics, clinical outcomes, and complications were collected. Cement extravasation, spinal hardware integrity, and fusion rates were assessed on CT scans. RESULTS Among 50 patients with follow-up imaging, 23 patients (46%) showed facet joint fusion. The length of segmental stabilization was not a significant predictor of the occurrence of fusion. Pre- or postoperative radiation therapy, postoperative chemotherapy, and the location of spinal lesions did not have a statistically significant effect on the occurrence of fusion. Patients older than 60 years of age were more likely to have fusion across facet joints compared with younger patients. There was a significant difference in the mean visual analog scale pain score, with 6.28 preoperatively and 3.41 postoperatively, regardless of fusion status (p < 0.001). Cement extravasation was seen in 51% of the cohort, but in all instances, patients remained asymptomatic. Most importantly, the incidence of hardware failure was low (4%). CONCLUSIONS Percutaneous fixation with cement-augmented pedicle screws in patients with pathological spine fractures provides an improvement in mechanical back pain, with a low incidence of failure, and in some patients, spontaneous facet fusion was observed. Further research is necessary with regard to both short-term benefits and long-term outcomes.
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Affiliation(s)
- Ahmed Meleis
- 1Department of Neurosurgery, MD Anderson Cancer Center; and
| | | | | | - Matthew T Muir
- 3School of Medicine, Baylor College of Medicine, Houston, Texas
| | - Ganesh Rao
- 1Department of Neurosurgery, MD Anderson Cancer Center; and
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Di Perna G, Cofano F, Mantovani C, Badellino S, Marengo N, Ajello M, Comite LM, Palmieri G, Tartara F, Zenga F, Ricardi U, Garbossa D. Separation surgery for metastatic epidural spinal cord compression: A qualitative review. J Bone Oncol 2020; 25:100320. [PMID: 33088700 PMCID: PMC7559860 DOI: 10.1016/j.jbo.2020.100320] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 08/31/2020] [Accepted: 09/07/2020] [Indexed: 02/07/2023] Open
Abstract
Separation surgery is a new concept for metastatic spinal cord compression treatment. Stereotactic radiosurgery increased local control, overcoming radio-resistance’s idea. The surgery goal shifted towards creating targets for radiations avoiding cord damages. Minimal invasive strategies could allow quick return to systemic therapies.
Introduction The new concept of separation surgery has changed the surgical paradigms for the treatment of metastatic epidural spinal cord compression (MESCC), shifting from aggressive cytoreductive surgery towards less invasive surgery with the aim to achieve circumferential separation of the spinal cord and create a safe target for high dose Stereotactic Body Radiation Therapy (SBRT), which turned out to be the real game-changer for disease’s local control. Discussion In this review a qualitative analysis of the English literature has been performed according to the rating of evidence, with the aim to underline the increasingly role of the concept of separation surgery in MESCC treatment. A review of the main steps in the evolution of both radiotherapy and surgery fields have been described, highlighting the important results deriving from their integration. Conclusion Compared with more aggressive surgical approaches, the concept of separation surgery together with the advancements of radiotherapy and the use of SBRT for the treatment of MESCC showed promising results in order to achieve a valuable local control while reducing surgical related morbidities and complications.
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Key Words
- CTV, Clinical tumor volume
- Carbon fiber/PEEK cement
- ECOG PS, Eastern Cooperative Oncology Group Performance Status Scale
- ESCC, Epidural Spinal Cord Compression
- Epidural spinal cord compression
- GTV, Gross tumor volume
- KPS, Karnofsky Performance Status
- LC, Local Control
- LITT, Laser Interstitial Thermal Therapy
- MAS, Minimal Access Spine
- MESCC, Metastatic Epidural Spinal Cord Compression
- MIS techniques
- MIS, Minimally Invasive Surgical
- NSCLC, Non-Small Cell Lung Cancer
- NSE, Neurologic Stability Epidural compression
- PEEK, Polyetheretherketone
- PLL, Posterior Longitudinal Ligament
- PMMA, Poly-Methyl-Methacrylate
- PRV, Spinal cord planning risk volume
- PTV, Planning target volume
- SBRT, Stereotactic Body Radiation Therapy
- SINS, Spinal Instability Neoplastic Score
- SRS, Stereotactic Radiosurgery
- SS, Separation Surgery
- Separation surgery
- Spinal metastases
- Stereotactic body radiation therapy
- cEBRT, conventional External Beam Radiation Therapy
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Affiliation(s)
- Giuseppe Di Perna
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
| | - Fabio Cofano
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
- Spine Surgery, Humanitas Gradenigo, Turin, Italy
- Corresponding author at: Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Via Cherasco 15, 10126 Turin, Italy.
| | - Cristina Mantovani
- Radiation Oncology Unit, Department of Oncology, University of Turin and Città della Salute e della Scienza Hospital, Via Genova 3, 10126 Turin, Italy
| | - Serena Badellino
- Radiation Oncology Unit, Department of Oncology, University of Turin and Città della Salute e della Scienza Hospital, Via Genova 3, 10126 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
| | - Ludovico Maria Comite
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
| | - Giuseppe Palmieri
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
| | - Fulvio Tartara
- Neurosurgery Unit, Istituto Clinico Città Studi, Milan, Italy
| | - Francesco Zenga
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
| | - Umberto Ricardi
- Radiation Oncology Unit, Department of Oncology, University of Turin and Città della Salute e della Scienza Hospital, Via Genova 3, 10126 Turin, Italy
| | - Diego Garbossa
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
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