Prognostic scoring systems for spinal metastases in the era of anti-VEGF therapies

Clinical outcomes following total en bloc spondylectomy for spinal metastases from lung cancer

BACKGROUND

The current guidelines for the treatment of non-small cell lung cancer encourage local curative treatment for selected patients with oligometastases. This study evaluated the surgical results of total en bloc spondylectomy (TES) for isolated spinal metastases originating from lung cancer in carefully selected patients.

METHODS

We retrospectively reviewed 14 patients (7 men and 7 women) who underwent TES for spinal metastases originating from lung cancer between 2000 and 2017. The primary outcome measure was the postoperative overall survival time. The histological types included adenocarcinoma (n = 12), pleomorphic carcinoma (n = 1), and small cell lung carcinoma (SCLC) (n = 1 patient). We assessed postoperative survival using Kaplan-Meier analysis and the log-rank test.

RESULTS

The median postoperative survival time was 83.0 months (6-162 months) in 13 patients with non-small cell lung carcinoma (NSCLC) and 6 months in 1 patient with SCLC. The 3-, 5-, and 10-year overall survival rates in patients with NSCLC were 61.5%, 53.8%, and 15.4%, respectively. Poor postoperative performance status (PS) and Frankel grade, and preoperative irradiation to the vertebrae to be resected were significantly associated with short-term survival after TES in patients with NSCLC (p < 0.05).

CONCLUSIONS

The surgical results of TES for spinal metastases of lung cancer were relatively favorable among carefully selected patients. TES may be indicated for spinal metastases of lung cancer in patients with controlled primary lung cancer, NSCLC histology, prospect of good postoperative PS, and preferably no irradiation to the target vertebrae.

Six-Month Survivorship Prediction in Spinal Metastatic Patients by Oncologists Shows Reliable Prognostication

STUDY DESIGN

A retrospective analysis of oncologist-provided prognoses vs actual survival outcomes of patients referred with Metastatic spinal cord compression (MSCC) to a supra-regional multidisciplinary team (MDT).

OBJECTIVES

Prognostic scoring systems, such as the revised Tokuhashi, are commonly used to help guide the treatment of MSCC. However, scoring systems do not accommodate for the improved outcomes of contemporary cancer therapy. Oncologist-provided prognoses play an important role in real world rapid decision making. There is a paucity of evidence assessing the accuracy of the oncologist-provided prognosis. We conducted a retrospective study to evaluate this.

METHODS

Data was captured between January 2015 and December 2018. Patients were split into 2 groups: Group 1 (prognosis estimated <6 months) and Group 2 (prognosis estimated >6 months). Median overall survival (mOS) and hazard ratio for death (HR) was assessed. Receiver operating characteristic (ROC) analysis was performed to assess the accuracy of the oncologist's prognosis.

RESULTS

829 patients were included. mOS in Group 1 was 5.8 months (95% CI 4.2-7.4 m), and in Group 2 mOS was not reached. Log rank test gave a Chi2 of 131 (P < .001). Cox regression analysis revealed a HR of .30 (P < .001). Area under the ROC curve was 78%.

CONCLUSIONS

Oncologist-provided prognosis is accurate in this cohort of unselected, consecutive MSCC patients. It reduced reliance on scoring systems that can become outdated. Given the rapid progress in cancer treatment, the oncologist's prognostic prediction is integral in efficient and effective MSCC management to help rapidly determine surgical candidacy.

Critical evaluation of the literature on decision-making in spinal metastases

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.

[Translated article] Critical evaluation of the literature on decision-making in spinal metastases

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.

Management of pain in patients with bone metastases

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.

Prediction of post-radiotherapy survival for bone metastases: a comparison of the 3-variable number of risk factors model with the new Katagiri scoring system

We investigated patient survival after palliative radiotherapy for bone metastases while comparing the prognostic accuracies of the 3-variable number of risk factors (NRF) model and the new Katagiri scoring system (Katagiri score). Overall, 485 patients who received radiotherapy for bone metastases were grouped as per the NRF model (groups I, II and III) and Katagiri score (low-, intermediate- and high-risk). Survival was compared using the log-rank or log-rank trend test. Independent prognostic factors were identified using multivariate Cox regression analyses (MCRA). MCRA and receiver operating characteristic (ROC) curves were used to compare both models' accuracy. For the 376 evaluable patients, the overall survival (OS) rates decreased significantly in the higher-tier groups of both models (P < 0.001). All evaluated factors except 'previous chemotherapy status' differed significantly between groups. Both models exhibited independent predictive power (P < 0.001). Per NRF model, hazard ratios (HRs) were 1.44 (P = 0.099) and 2.944 (P < 0.001), respectively, for groups II and III, relative to group I. Per Katagiri score, HRs for intermediate- and high-risk groups were 4.02 (P < 0.001) and 7.09 (P < 0.001), respectively, relative to the low-risk group. Areas under the curve (AUC) for predicting 6-, 18- and 24-month mortality were significantly higher when using the Katagiri score (P = 0.036, 0.039 and 0.022). Both models predict survival. Prognostic accuracy of the Katagiri score is superior, especially in patients with long-term survival potential; however, in patients with short prognosis, no difference occurred between both models; simplicity and patient burden should also be considered.

Comprehensive surgical treatment strategy for spinal metastases

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.

Modified score based on revised Tokuhashi score is needed for the determination of surgical intervention in patients with lung cancer metastases to the spine

BACKGROUND

Revised Tokuhashi score (RTS) is no longer accurate to predict the survival of patients with lung cancer metastases to the spine. This study is to identify additional prognostic factors in those patients, develop a modified prognostic score based on RTS, and verify the accuracy of the score in prediction.

METHODS

Our study included patients with lung cancer metastases to the spine who underwent surgery for spine metastasis. Potential prognostic factors were analyzed. Points were allocated for prognostic factors obtained from survival analyses. A modified score was developed by including prognostic factors and their points to RTS. Accuracy of the modified score was evaluated by comparing the coincidence between predicted and observed survival. Kaplan-Meier analysis and Cox regression models were used. Predictive values of scores for 6-month survival were measured via receiver operating characteristic (ROC) curves.

RESULTS

Targeted therapy and tumor markers were additional independent prognostic factors. In the modified score, 2 and 1 points were allocated to the new evaluation factors. The points for factors based on RTS remained the same, and two prognostic groups were redefined. For group A patients who were predicted to live for less than 6 months, conservative procedures would be recommended. For group B patients who were predicted to live for 6 months or more, palliative surgery would be recommended. When comparing the modified score to RTS, the area under the receiver operating characteristic curve (AUCROC) and accuracy of score were improved.

CONCLUSIONS

The modified RTS has improved prognostic accuracy in patients with lung cancer metastases to the spine.

Prediction Accuracy of Common Prognostic Scoring Systems for Metastatic Spine Disease: Results of a Prospective International Multicentre Study of 1469 Patients

STUDY DESIGN

A prospective multicenter cohort study.

OBJECTIVE

To assess the clinical accuracy of six commonly cited prognostic scoring systems for patients with spinal metastases.

SUMMARY OF BACKGROUND DATA

There are presently several available methods for the estimation of prognosis in metastatic spinal disease, but none are universally accepted by surgeons for clinical use. These scoring systems have not been rigorously tested and validated in large datasets to see if they are reliable enough to inform day-to-day patient management decisions. We tested these scoring systems in a large cohort of patients. A total of 1469 patients were recruited into a secure internet database, and prospectively collected data were analyzed to assess the accuracy of published prognostic scoring systems.

METHODS

We assessed six prognostic scoring systems, described by the first authors Tomita, Tokuhashi, Bauer, van der Linden, Rades, and Bollen. Kaplan-Meier survival estimates were created for different patient subgroups as described in the original publications. Harrell's C-statistic was calculated for the survival estimates, to assess the concordance between estimated and actual survival.

RESULTS

All the prognostic scoring systems tested were able to categorize patients into separate prognostic groups with different overall survivals. However none of the scores were able to achieve "good concordance" as assessed by Harrell's C-statistic. The score of Bollen and colleagues was found to be the most accurate, with a Harrell's C-statistic of 0.66.

CONCLUSION

No prognostic scoring system was found to have a good predictive value. The scores of Bollen and Tomita were the most effective with Harrell's C-statistic of 0.66 and 0.65, respectively. Prognostic scoring systems are calculated using data from previous years, and are subject to inaccuracies as treatments advance in the interim. We suggest that other methods of assessing prognosis should be explored, such as prognostic risk calculation.

LEVEL OF EVIDENCE

3.

Kidney and Thyroid Cancer-Specific Treatment Algorithm for Spinal Metastases: A Validation Study

BACKGROUND

Spinal metastases (SMs) from kidney and thyroid cancers have several common features suggesting that excisional surgery for isolated and removable SMs can improve survival. We propose a simple treatment algorithm for SMs from these cancers. Our study aimed to evaluate the efficacy of the algorithm.

METHODS

We performed a retrospective analysis of the data of 69 consecutive patients (48 with kidney and 21 with thyroid cancers) who underwent excisional surgery for SMs between 1995 and 2014. The patients were retrospectively classified into an indicated group for excisional SM surgery and a nonindicated group according to our algorithm, and the Tokuhashi and Tomita scoring systems. Patients in the indicated group were expected to survive ≥2 years postoperatively, whereas those in the nonindicated group were not. The positive predictive value and negative predictive value (NPV) were calculated using the predicted versus actual survival times of the patients. Survival was defined as the time from the first excisional surgery for the spinal lesion to death or the last follow-up of ≥2 years.

RESULTS

For patients with kidney cancer, the 2- and 5-year survival rates were 85.4% and 60.4%, respectively. For patients with thyroid cancer, the 2- and 5-year survival rates were 100% and 83.8%, respectively. Our algorithm had a compatible high positive predictive value (95.5%) and NPV (100%), whereas the Tokuhashi and Tomita scoring systems had low NPVs of 15.8% and 13.3%, respectively.

CONCLUSIONS

Our treatment algorithm of SMs from kidney and thyroid cancers is useful for determining an adequate treatment including excisional surgery.

Clinical Results of Minimally Invasive Spine Stabilization for the Management of Metastatic Spinal Tumors Based on the Epidural Spinal Cord Compression Scale

Purpose

Minimally invasive spine stabilization (MISt) using percutaneous pedicle screws plays a significant role in palliative surgery for metastatic spinal tumors. However, few studies have investigated surgical outcomes based on the epidural spinal cord compression scale (ESCCS). The purpose of this study was to examine outcomes of metastatic spinal tumors as evaluated by ESCCS in patients treated by MISt.

Methods

The subjects were 56 patients who underwent MISt for metastatic spinal tumors, including 34 patients with ESCCS 2 or milder (group A) and 22 patients with ESCCS 3 (group B). We analyzed baseline characteristics, perioperative factors and clinical results such as postoperative survival time, neurological outcomes, Barthel Index for activities of daily living (ADL), visual analogue scale (VAS), and the rate of discharge to home.

Results

The baseline age (P=0.07), tumor diagnosis (P=0.23), spinal level of compression (P=0.35), American Spinal Injury Association classification (P=0.49), revised Tokuhashi score (P=0.92), spinal instability neoplastic score (P=0.28), VAS (P=0.35), Barthel Index (P=0.07), American Society of Anesthesiologists physical status classification (P=0.76), and type of surgery (P=0.40) did not differ significantly between the two groups. The median postoperative survival time did not differ significantly between the groups (12.0 versus 15.0 months, P=0.60). Neurological improvement by at least 1 grade or maintenance of grade E was favorable in group A. Patients in group A had less posterior decompression (P=0.006), a higher rate of chemotherapy (P=0.009), a higher postoperative Barthel Index (P=0.04), and a higher rate of discharge to home (P=0.01) and no patients died in the hospital (P=0.004).

Conclusions

No significant difference was noted in the postoperative survival time between the 2 groups. Patients in the ESCCS 2 or milder group had favorable neurological improvement, higher rates of chemotherapy, better postoperative ADL, and the higher rate of discharge to home.

Prognostic factors in patients with metastatic spine tumors derived from lung cancer-a novel scoring system for predicting life expectancy

BACKGROUND

Recently, molecule-targeting and bone-modifying agents have improved the treatment outcomes of lung cancer-derived metastatic spine tumors. Therefore, the prognostic factors for such tumors were examined, and novel scoring systems for predicting the life expectancy of patients with such tumors were proposed.

METHODS

In 207 patients with lung cancer-derived metastatic spine tumors (surgery 49; conservative therapy 158), we retrospectively examined the factors that influenced the post-treatment survival time (age, sex, the affected site, pathology, general condition, the number of extraspinal bone metastases, the number of spinal metastases, the presence/absence of major internal organ metastasis, paralysis state, the total Tokuhashi score, the serum alkaline phosphatase level, the serum carcinoembryonic antigen level, molecule-targeting drug treatment, and bone-modifying agent treatment). Based on the results, we devised novel scoring systems for predicting the prognosis of such patients.

RESULTS

Univariate analyses showed that the pathology of the primary lung tumor, the patient's general condition and paralysis state, and the presence/absence of molecule-targeting drug treatment significantly influenced survival. We performed a Cox regression analysis of these four factors and developed criteria for a novel scoring system based on the patient's general condition and paralysis state, which exhibited significance in the regression analysis. A retrospective review indicated that the consistency rate between predicted life expectancy and actual survival was 67.3%. When criteria based on the four factors that exhibited significance in the univariate analyses were adopted, the consistency rate was 76.2%.

CONCLUSION

The patient's general condition and paralysis state, the pathology of the primary lung tumor, and molecule-targeting drug treatment influenced survival among patients with lung cancer-derived metastatic spine tumors. Novel scoring systems based on these four factors were proposed.

Prediction of survival in patients with symptomatic spinal metastases: Comparison between the Tokuhashi score and expert oncologists

BACKGROUND

Existing scoring systems have suboptimal accuracy in prognosticating patients with spinal metastases. Currently, there is no superior method in predicting survival. This study aims to compare the accuracy of survival prediction by expert oncologists versus the revised Tokuhashi scores with actual survivals in a cohort of symptomatic spinal metastases patients.

METHODS

All patients who underwent surgical treatment for metastatic spinal tumours in a tertiary hospital between January 2011 to December 2015 were reviewed. Each patient's data was reconstructed into an anonymised clinical scenario and presented independently to five blinded attending oncologists with at least three years' post fellowship experience. They were surveyed for survival prediction twice at no less than four weeks' interval apart; the test-retest reliability was examined. The agreement of their prognostication and modified Tokuhashi scores were compared with actual survivals.

RESULTS

Fifty-five patients were included during the study period. The mean age at presentation was 61.1 years (range, 41 to 79), and mean actual survival was 21.6 months (range, 1 to 68). Cohen's kappa agreement with actual survival was higher by oncologists' estimation (0.52) than by revised Tokuhashi score prediction (0.31) (p = 0.018). Intra-class correlation showed high inter-reliability (0.71) between the five oncologists and a high test-retest reliability (0.69) between both rounds of the survey.

CONCLUSION

This study showed that expert oncologists provided more accurate survival prediction than revised Tokuhashi scores in patients with spinal metastases. Future studies are required to identify factors in their assessment that led to improved accuracy.

Classification and scoring systems for metastatic spine tumors: a literature review

Introduction

Accurate evaluation of metastasis and life prognosis is essential for selecting a suitable therapeutic strategy for metastatic spine tumors owing to limitations in treatment options. For this purpose, various classification, evaluation, and scoring systems have been developed.

Methods

Classification, evaluation, and scoring systems for metastatic spine tumors reported to date were identified by performing a literature search on PubMed. We reviewed the most cited classifications and scorings before 2009, and all classifications and scorings reported after 2010 from the search results.

Results

Six classifications and 23 scorings were reviewed. The classification/evaluation methods are divided into 1) anatomical classification/evaluation methods, 2) evaluation methods for neurological symptoms/instability, and 3) scoring systems for predicting life expectancy. The first 2 were useful for the planning and evaluation of surgical indications. Scoring systems for life prognosis also permitted rough prediction of the outcomes and were useful for the selection of a suitable treatment. However, variation of the patient background, diversity of adopted prognostic factors, and the absence of scoring systems that could predict the outcome with an accuracy of 90% or higher introduced some limitations.

Conclusion

The identified classification, evaluation, and scoring systems have been generally useful for treatment strategies. However, we emphasize the necessity of multidisciplinary development and revision of classification and evaluation methods to adapt to the prolongation of survival associated with increased diversity and improvement of treatment options.

Treatment Outcome of Metastatic Spine Tumor in Lung Cancer Patients: Did the Treatments Improve Their Outcomes?

STUDY DESIGN

A retrospective, single-center study.

OBJECTIVE

Investigation of the changes in the treatment outcomes of patients with lung cancer derived metastatic spine tumors.

SUMMARY OF BACKGROUND DATA

Metastatic spine tumors derived from lung cancer had been progressive, and their prognosis is poor. It has recently been reported that the use of molecularly targeted drugs and bone-modifying agents (BMAs) improved the treatment outcomes of patients with lung cancer, but no detailed information about the treatment of metastatic spine tumors has been reported.

METHODS

Two hundred seven patients with lung cancer derived metastatic spine tumors who were examined after 2000 were analyzed. They were divided into 54 patients who were treated in or before 2005 (surgical treatment: 25 patients, conservative treatment: 29 patients) (group B) and 153 patients who were treated from 2006 onwards, when a molecularly targeted drug and BMA were introduced (surgical treatment: 24, conservative treatment: 129) (group A), and the treatment outcomes of the two groups were compared.

RESULTS

Significant differences in age and the affected vertebral level, paralysis grade, and Tokuhashi score (general condition, the number of vertebral metastases, and the total score) were detected between the groups. Regarding treatment outcomes, the mean duration of the post-treatment survival period was 5.1 and 9.3 months in groups B and A, respectively, that is, it was significantly longer in group A (P < 0.05). No significant intergroup difference in pain improvement was noted, and no significant post-treatment improvement in paralysis was achieved in either group. The post-treatment discharge-to-home eligibility rate did not differ significantly between the groups, but the Barthel Index improved significantly after treatment in group A (P < 0.05).

CONCLUSION

After molecularly targeted drugs and BMA were introduced as treatments for lung cancer derived metastatic spine tumors, the survival periods of patients with such tumors increased, and their activity of daily living after treatment improved.

LEVEL OF EVIDENCE

4.

Overall survival and prognostic factors in patients with spinal metastases from lung cancer treated with and without epidermal growth factor receptor tyrosine kinase inhibitors

BACKGROUND

Evaluation of the prognosis in patients with spinal metastases is important in decision making regarding surgical treatment. The purpose of this study was to investigate overall survival in patients with spinal metastases from lung cancer by histological subtype, and to investigate prognostic factors in patients treated with and without epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs).

METHODS

The data from 135 patients diagnosed with spinal metastases from lung cancer were retrospectively evaluated. The 88 patients with adenocarcinoma were divided into two groups according to whether the lung cancer was treated with or without EGFR-TKIs-the EGFR-TKI group (n = 43) and the non-EGFR-TKI group (n = 45).

RESULTS

The overall median survival time was 11.3 months for those with adenocarcinoma, 5.3 months for squamous cell carcinoma, and 3.9 months for small cell carcinoma. Overall survival in the EGFR-TKI group (median 21.4 months) was significantly longer than in the non-EGFR-TKI group (median 6.1 months). In univariate analysis, poor performance status was a poor prognostic factor in the non-EGFR-TKI group. However, performance status and other variables were not significant prognostic factors in the EGFR-TKI group.

CONCLUSIONS

Median overall survival was longer in patients with spinal metastases from lung cancer treated with EGFR-TKIs compared with those treated without EGFR-TKIs. Poor performance status or other prognostic factors were not associated with poor overall survival in the group treated with EGFR-TKIs.

Evaluation of Scoring Systems and Prognostic Factors in Patients With Spinal Metastases From Lung Cancer

STUDY DESIGN

A retrospective study of 180 patients with lung cancer spinal metastases, wherein prognostic score-predicted survival was compared with actual survival.

OBJECTIVE

To evaluate and compare the accuracy of prognostic scoring systems in lung cancer spinal metastases.

SUMMARY OF BACKGROUND DATA

The modified Tokuhashi, Tomita, modified Bauer, and Oswestry scores are currently used to guide decisions regarding operative treatment of patients with spinal metastases. The best system for predicting survival in patients with lung cancer spinal metastases remains undetermined. The high incidence of spinal metastases from lung cancer and improved survival of patients treated with systemic therapy warrants evaluation of these scoring systems in this particular context.

METHODS

Patients with lung cancer spinal metastases treated at our institution between May 2001 and August 2012 were studied. Fifty-one patients were treated surgically. The primary outcome measure was survival from the time of diagnosis. Scoring-predicted survival was compared with actual survival. Potential prognostic factors were investigated using Cox regression analyses. Predictive values of each scoring system for 3- and 6-month survival were measured via receiver operating characteristic (ROC) curves.

RESULTS

Histological subtype (P = 0.015), sex (P = 0.001), Karnofsky performance scale (P = 0.001), extent of neurological palsy (P = 0.002), and visceral metastases (P = 0.037) are significant predictors of survival. Besides the Oswestry spinal risk index, no significant differences were found between different prognostic subgroups within the individual scoring systems. Although the modified Bauer score was most accurate, all four scoring systems had areas under the ROC curve 0.5 or less.

CONCLUSION

Although better prognostic scores correlated with longer survival, all four scoring systems are inaccurate in prognosticating patients with lung cancer spinal metastases. Specific lung cancer histology appears prognostic and should be considered, especially given the increased survival of patients receiving new targeted therapies appropriate to their disease.

LEVEL OF EVIDENCE

3.

Prognostic factors associated with survival in patients with symptomatic spinal bone metastases: a retrospective cohort study of 1,043 patients

BACKGROUND

Expected survival is a major factor influencing extent of treatment for symptomatic spinal bone metastases (SBM). Predictive models have been developed, but their use can lead to over- or undertreatment.. The study objective was to identify prognostic factors associated with survival in patients with symptomatic SBM and to create a validated risk stratification model.

METHODS

All patients who were treated for symptomatic SBM between 2001 and 2010 were included in this single center retrospective study. Medical records were reviewed for type of primary cancer, performance status, presence of visceral, brain and bone metastases, number and location of spinal metastases, and neurological functioning. Performance status was assessed with the Karnofsky performance score and neurological functioning with the Frankel scale. Analysis was performed using Kaplan-Meier curves, univariate log-rank tests, Cox regression models, and Harrell's C statistic.

RESULTS

A total of 1 043 patients were studied. The most prevalent tumors were those of breast (n = 299), lung (n = 250), and prostate (n = 215). Median follow-up duration was 6.6 years, and 6 patients were lost to follow-up. Based on the results of the uni- and multivariate analyses, 4 categories were created. Median survival in category A was 31.2 months (95% CI, 25.2-37.3 months), 15.4 months (95% CI, 11.9-18.2 months) for category B, 4.8 months (95% CI, 4.1-5.4 months) for category C, and 1.6 months (95% CI, 1.4-1.9 months) for category D. Harrell's C statistic was calculated after the model was applied to an external dataset, yielding a result of 0.69.

CONCLUSION

Assessing patients according to the presented model results in 4 categories with significantly different survival times.

Scoring system for prediction of metastatic spine tumor prognosis

Assessing the prognosis before treatment for metastatic spine tumor is extremely important in therapy selection. Therefore, we review some prognostic scoring systems and their outcomes. Articles with combinations of two keywords among “metastatic spine tumor” and “prognosis”, “score”, “scoring system”, “predicting”, or “life expectancy” were searched for in PubMed. As a result, 236 articles were extracted. Those referring to representative scoring systems about predicting the survival of patients with metastatic spine tumors were used. The significance and limits of these scoring systems, and the future perspectives were described. Tokuhashi score, Tomita score, Baur score, Linden score, Rades score, and Katagiri score were introduced. They are all scoring systems prepared by combining factors that affect prognosis. The primary site of cancer and visceral metastasis were common factors in all of these scoring systems. Other factors selected to influence the prognosis varied. They were useful to roughly predict the survival period, such as, “more than one year or not” or “more than six months or not”. In particular, they were utilized for decision-making about operative indications and avoidance of excessive medical treatment. Because the function depended on the survival period in the patients with metastatic spine tumor, it was also utilized in assessing functional prognosis. However, no scoring system had more than 90% consistency between the predicted and actual survival periods. Future perspectives should adopt more oncological viewpoints with adjustment of the process of treatment for metastatic spine tumor.

Moderate precision of prognostic scoring systems in a consecutive, prospective cohort of 544 patients with metastatic spinal cord compression

PURPOSE

Improved survival among cancer patients and diverse conclusions from recent studies make it relevant to reassess the performance of the Tokuhashi Revised score and the Tomita score. The aim of this study was to validate and compare these two scoring systems in a recent and unselected cohort of patients with metastatic spinal cord compression (MSCC).

METHODS

In 2011, we conducted a prospective cohort study of 544 patients who were consecutively admitted with MSCC to one treatment facility. Patients estimated survival were assessed with the Tokuhashi Revised score and the Tomita score and compared to the observed survival. We assessed how precise the scoring systems predicted survival with McNemar's test. The prognostic value was illustrated with Kaplan-Meier curves, and the individual prognostic components were analyzed with Cox regression analysis.

RESULTS

The mean age was 65 years (range 20-95), and 57 % of the patients were men. The majority of tumors were lung (23 %), prostate (21 %), and breast tumors (18 %). The overall precision of predicted survival was 58.7 % for the Tokuhashi Revised score and 52.9 % for the Tomita score. The observed survival in each of the scoring groups categorized by the scoring systems was statistically significantly different (p < 0.0001).

CONCLUSIONS

The Tokuhashi Revised score and the Tomita score are useful in categorizing patients into prognostic groups, and the individual components have important prognostic values. The Tokuhashi Revised score was most precise in predicting survival. However, due to the relatively low precision, we suggest that a modification of both scoring systems is necessary.