Malignant spinal cord compression: prospective study of delays in referral and treatment

Epidemiology of Surgically Treated Spinal Tumors: A Multicenter Surveillance Study of 9686 Patients from the German Spine Registry (DWG Register)

Tumors of the spine are challenging in terms of diagnoses and interdisciplinary treatment. This study was conducted to evaluate and characterize a large multicenter cohort of surgically treated spine tumor patients.Data of the German Spine Society (DWG) were used to characterize a cohort of all surgically treated spine tumor cases that were registered between 2017 and 2021. Subgroup analysis was performed for tumor entity, tumor localization, height of most severely affected segments, surgical treatment, and demographic parameters.In total, there were 9686 cases, of which 6747 were "malignant", 1942 were "primary benign", 180 were "tumor-like lesions", and 488 were "other" spinal tumors. Subgroups showed differences in number of affected segments as well as localization. There were further significant differences in surgical complication rates (p = 0.003), age (p < 0.001), morbidity (p < 0.001), and duration of surgery (p = 0.004).This is a representative study on spinal tumors from a large spine registry and allows for the epidemiological characterization of surgically treated tumor subgroups and quality control of registry data.

Advances in Surgery for Metastatic Disease of the Spine: An Update for Oncologists

STUDY DESIGN

Narrative review.

OBJECTIVE

Metastatic spine disease is an increasingly common clinical challenge that requires individualised multidisciplinary care from spine surgeons and oncologists. In this article, the authors describe the recent surgical advances in patients presenting with spinal metastases.

METHODS

We present an overview of the presentation, assessment, and management of spinal metastases from the perspective of the spine surgeon, highlighting advances in surgical technology and techniques, to facilitate multidisciplinary care for this complex patient group. Neither institutional review board approval nor patient consent was needed for this review.

RESULTS

Advances in radiotherapy delivery and systemic therapy (including immunotherapy and targeted therapy) have refined operative indications for decompression of neural structures and spinal stabilisation, while advances in surgical technology and technique enable these goals to be achieved with reduced morbidity. Formulating individualised management strategies that optimise outcome, while meeting patient goals and expectations, requires a comprehensive understanding of the factors important to patient management.

CONCLUSION

Spinal metastases require prompt diagnosis and expert management by a multidisciplinary team. Improvements in systemic, radiation, and surgical therapies have broadened operative indications and increased operative candidacy, and future advances are likely to continue this trend.

Impact of metastatic epidural spinal cord compression (MESCC) and pathological vertebral compression fracture (pVCF) in neurological and survival prognosis

BACKGROUND

Metastatic epidural spinal cord compression (MESCC) and pathological vertebral compression fractures (pVCF) are the most serious debilitating morbidities of spine metastases (SpMs) causing devastating neurological damages. The respective impact of these two metastasis-spreading entities on survival and on neurological damage is debated.

METHODS

A French prospective cohort study collected 279 consecutive patients presenting with SpMs between January 2017 and 2021. We compared 174 patients with MESCC and 105 patients with pVCF.

RESULTS

The median Overall Survival (OS) for the MESCC group was 13.4 months (SD 1.5) vs 19.2 months (SD 2.3) for pVCF patients (p = 0.085). Sixty-five patients (23.3 %) were operated on: 49/65 (75.4 %) in the MESCC group and 16/65 (15.2 %) in the pVCF group, p < 0.0001. At 6 months FU, in the MESCC group, 21/44 (45.4 %) of non-ambulatory patients at onset improved to ambulatory status (Frankel D-E) vs 10/13 (76.9 %) in the pVCF group (p = 0.007). In multivariable analysis with the Cox proportional hazard model, good ECOG-PS and SINS Score 7-12 [HR: 6.755, 95 % CI 2.40-19.00; p = 0.001] were good prognostic factors for preserved ambulatory neurological status. However, SpMs diagnosed synchronously with the primary tumor [HR: 0.397, 95 % CI 0.185-0.853; p = 0.018] and MESCC [HR: 0.058, 95 % CI 0.107-0.456; p = 0.007] were independent risk factors for impaired neurological function.

CONCLUSION

Contrary to pVCF, MESCC causes neurological damage. Nevertheless, neurological recovery remains possible. MESCC and pVCF have no impact on survival. The management of MESCC remains to be clarified and optimized to reduce neurological damage.

Enhancing the referral process for surgical management of spinal metastases: insights from a 12-year, bi-institutional study of 533 patients

Introduction

Delayed surgical management of spinal metastases (SMs) can have detrimental effects on patient survival and quality of life, leading to pain and potential neurological impairment. This study aimed to assess the impact of delayed referral for SMs on clinical outcomes by analyzing patients managed in emergency situations.

Methods

We retrospectively reviewed the data of all patients admitted on either emergency or elective basis who underwent surgery for the treatment of neoplastic spine lesions at our two institutions (tertiary referral neurosurgical units) between January 2008 and December 2019.

Results

We analyzed 210 elective (EGp) and 323 emergency patients (UGp); emergencies increased significantly over the 12-year period, with a Friday peak (39.3%) and frequent neurological impairment (61.6% vs. 20%). Among the UGp patients, 186 (7.5%) had a previously monitored primitive cancer, including 102 (31.6%) with known SMs. On admission, 71 of the 102 (69.9%) patients presented with neurological deficits. UGp patients were more likely to undergo a single decompression without fixation. Outcomes at the 3-month follow-up were significantly worse for UGp patients ([very] poor, 29.2 vs. 13.8%), and the median overall survival for UGp patients was statistically lower. Risk factors for patients with SM undergoing emergency management included short delay between onset of symptoms and first contact with a spine surgeon, and an initial motor deficit.

Conclusion

Many patients with previously identified metastases, including those with neurological deficits, are urgently referred. Optimization is needed in the oncology pathway, and all stakeholders must be made aware of the factors contributing to the improvement in the clinical and radiological identification of potential complications affecting patient survival and quality of life.

Radiologic reporting of MRI-proven thoracolumbar epidural metastases on body CT: 12-Year single-institution experience

RATIONALE AND OBJECTIVES

Metastatic epidural masses are an important radiological finding. The purpose of this study is to determine factors associated with non-reporting of thoracolumbar epidural metastases on body CT.

MATERIALS AND METHODS

In a study population of 166 patients from a single institution over a 12-year period, 293 body CT examinations were identified which were performed within 30 days before or after a spine MRI diagnosis of epidural metastasis. Associations were sought between patient diagnosis, CT examination characteristics, reporting radiologist (n = 17), and lesion characteristics with respect to whether an epidural metastasis was reported on CT.

RESULTS

In retrospective consensus review comprised of 3 radiologists, epidural metastases reported on spine MRI were clearly visible in 80.5% (236/293) of body CT examinations, however 65.3% (154/236) of the body CT reports omitted reporting their presence, even in cases where there was a preceding MRI diagnosis within 30 days (65.4%, 74/113). The identity of the reporting radiologist was statistically significantly associated with the accurate diagnostic reporting of epidural metastasis on body CT (p = 0.04). The only lesion features which were statistically significantly associated with CT reporting were lesion volume (p = 0.03) on noncontrast CT, and lesion volume (p = 0.006) and percentage of spinal canal stenosis (p = 0.001) on intravenous contrast-enhanced CT. The presence or absence of intravenous contrast was not significantly associated with CT reporting (p = 1.0).

CONCLUSION

Using spine MRI as the reference standard for the presence of epidural tumor, the majority of body CT reports omit describing thoracolumbar epidural metastases which are clearly visible in retrospect.

Measuring the Delay in the Referral of Unstable Vertebral Metastasis to the Spine Surgeon: A Retrospective Study in a Latin American Institution

Background

The delay in the referral of patients with potential surgical vertebral metastasis (VM) to the spine surgeon is strongly associated with a worse outcome. The spinal instability neoplastic score (SINS) allows for determining the risk of instability of a spine segment with VM; however, it is almost exclusively used by specialists or residents in neurosurgery or orthopedics. The objective of this work is to report the delay in surgical consultation of patients with potentially unstable and unstable VM (SINS >6) at our center.

Material

We performed a 5-year single-center retrospective analysis of patients with spine metastasis on computed tomography (CT). Patients were divided into Group 1 (G1), potentially unstable VM (SINS 7-12), and Group 2 (G2), unstable VM (SINS 13-18). Time to surgical referral was calculated as the number of days between the report of the VM in the CT and the first clinical assessment of a spinal surgeon on the medical records.

Results

We analyzed 220 CT scans, and 98 met the selection criteria. Group 1 had 85 patients (86.7%) and Group 2 had 13 (13.3%). We observed a mean time to referral of 83.5 days in the entire cohort (std = 127.6); 87.6 days (std = 135.1) for G1, and 57.2 days (std = 53.8) for G2. The delay in referral showed no significant correlation with the SINS score.

Conclusion

We report a mean delay of 83.5 days in the surgical referral of VM (SINS >6, n = 98). Both groups showed cases of serious referral delay, with 25% of patients having the first surgical consultation more than three months after the CT study.

Time to Surgical Treatment for Metastatic Spinal Disease: Identification of Delay Intervals

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Minimizing delays in referral, diagnosis and treatment of patients with symptomatic spinal metastases is important for optimal treatment outcomes. The primary objective of this study was to investigate several forms of delay from the onset of symptoms until surgical treatment of spinal metastases for patients with and without a known preexisting known malignancy.

METHODS

All patients receiving surgical treatment for spinal metastases in a single tertiary spine center were identified. Referral patterns were reconstructed and the total delay was divided into 4 categories: patient delay (onset of symptoms until medical consultation), diagnostic delay (medical consultation until diagnosis), referral delay (diagnosis until referral to spine surgeon) and treatment delay (referral spine to surgeon until treatment). These intervals were compared between patients with and without a known preexisting malignancy.

RESULTS

The median total delay was 99 days, patient delay 19 days, diagnostic delay 21,5 days, referral delay 7 days, treatment delay 8 days and diagnosis and treatment delay combined 18,5 days. No difference in total delay was observed between patients with and without a known preexisting malignancy. Total delay was not significantly associated with patient age, sex, oncological history, tumor prognosis and spinal level of the tumor.

CONCLUSIONS

Patients with symptomatic spinal metastases experience considerable delays, even after metastatic spinal disease has been diagnosed, regardless of a preexisting malignancy. By identifying and eliminating the causes of these delays, diagnosis, referral and treatment may be expedited leading to improved patient outcome.

Imaging of metastatic epidural spinal cord compression

Metastatic epidural spinal cord compression develops in 5-10% of patients with cancer and is becoming more common as advancement in cancer treatment prolongs survival in patients with cancer (1-3). It represents an oncological emergency as metastatic epidural compression in adjacent neural structures, including the spinal cord and cauda equina, and exiting nerve roots may result in irreversible neurological deficits, pain, and spinal instability. Although management of metastatic epidural spinal cord compression remains palliative, early diagnosis and intervention may improve outcomes by preserving neurological function, stabilizing the vertebral column, and achieving localized tumor and pain control. Imaging serves an essential role in early diagnosis of metastatic epidural spinal cord compression, evaluation of the degree of spinal cord compression and extent of tumor burden, and preoperative planning. This review focuses on imaging features and techniques for diagnosing metastatic epidural spinal cord compression, differential diagnosis, and management guidelines.

Consensus Statement Supporting the Presence of Onsite Radiation Oncology Departments at VHA Medical Centers

BACKGROUND

Although multiple studies demonstrate that radiotherapy is underused worldwide, the impact that onsite radiation oncology at medical centers has on the use of radiotherapy is poorly studied. The Veterans Health Administration (VHA) Palliative Radiotherapy Taskforce has evaluated the impact of onsite radiation therapy on the use of palliative radiation and has made recommendations based on these findings.

OBSERVATIONS

Radiation consults and treatment occur in a more timely manner at VHA centers with onsite radiation therapy compared with VHA centers without onsite radiation oncology. Referring practitioners with onsite radiation oncology less frequently report difficulty contacting a radiation oncologist (0% vs 20%, respectively; P = .006) and patient travel (28% vs 71%, respectively; P < .001) as barriers to referral for palliative radiotherapy. Facilities with onsite radiation oncology are more likely to have multidisciplinary tumor boards (31% vs 3%, respectively; P = .11) and are more likely to be influenced by radiation oncology recommendations at tumor boards (69% vs 44%, respectively; P = .02).

CONCLUSIONS

The VHA Palliative Radiotherapy Taskforce recommends the optimization of the use of radiotherapy within the VHA. Radiation oncology services should be maintained where present in the VHA, with consideration for expansion of services to additional facilities. Telehealth should be used to expedite consults and treatment. Hypofractionation should be used, when appropriate, to ease travel burden. Options for transportation services and onsite housing or hospitalization should be understood by treating physicians and offered to patients to mitigate barriers related to travel.

Outcomes and efficiency of managing patients admitted for surgery for spinal metastases

Background:

This study evaluated the current pathways for dealing with patients admitted for surgery to address spinal metastases.

Methods:

In this retrospective analysis (2016–2021), the following variables were studied admission, demographics, length of stay, critical care admission, hospital costs, primary cancer, and average survival.

Results:

There were 306 patients admitted from 2016 to 2021; 66 were planned admissions, 203 were emergency admissions, and 37 were day case admission. Patients averaged 65.4 years old. About 75% (203) were emergently admitted, while 25% (66) had planned elective admissions. Their respective lengths of stay were 16.5 versus 5.74 days. Interestingly, nearly half of the emergency admissions (46.3%) did not have surgery during that admission. The most common level for metastatic disease was the thoracic spine in both groups (53% in the elective vs. 62% emergency groups). The most common primary lesions included lung, breast, and prostate in both groups. The average survival in the emergency admission group was 9.1 months and the planned admission group was 13.07 months. Notably, the costs of emergent care were much higher than planned admissions.

Conclusion:

The pathway for spinal metastases is unique in that though there is a pathway for late-stage disease, there is not one for early disease. As a result, the majority of patients admitted for surgery for spinal metastases come in as an emergency rather than as a planned admission. Yet, close to half do not end up having surgery during that emergency admission to the spinal center. The cost of emergency care is significantly higher versus planned elective care for spinal metastatic disease. A service transformation is suggested to combat these problems with a pathway for managing all spinal metastases, rather than just metastatic spinal cord compression.

Observation versus screening spinal MRI and pre-emptive treatment for spinal cord compression in patients with castration-resistant prostate cancer and spinal metastases in the UK (PROMPTS): an open-label, randomised, controlled, phase 3 trial

BACKGROUND

Early diagnosis of malignant spinal cord compression (SCC) is crucial because pretreatment neurological status is the major determinant of outcome. In metastatic castration-resistant prostate cancer, SCC is a clinically significant cause of disease-related morbidity and mortality. We investigated whether screening for SCC with spinal MRI, and pre-emptive treatment if radiological SCC (rSCC) was detected, reduced the incidence of clinical SCC (cSCC) in asymptomatic patients with metastatic castration-resistant prostate cancer and spinal metastasis.

METHODS

We did a parallel-group, open-label, randomised, controlled, phase 3, superiority trial. Patients with metastatic castration-resistant prostate cancer were recruited from 45 National Health Service hospitals in the UK. Eligible patients were aged at least 18 years, with an Eastern Co-operative Oncology Group performance status of 0-2, asymptomatic spinal metastasis, no previous SCC, and no spinal MRI in the past 12 months. Participants were randomly assigned (1:1), using a minimisation algorithm with a random element (balancing factors were treatment centre, alkaline phosphatase [normal vs raised, with the upper limit of normal being defined at each participating laboratory], number of previous systemic treatments [first-line vs second-line or later], previous spinal treatment, and imaging of thorax and abdomen), to no MRI (control group) or screening spinal MRI (intervention group). Serious adverse events were monitored in the 24 h after screening MRI in the intervention group. Participants with screen-detected rSCC were offered pre-emptive treatment (radiotherapy or surgical decompression was recommended per treating physician's recommendation) and 6-monthly spinal MRI. All patients were followed up every 3 months, and then at month 30 and 36. The primary endpoint was time to and incidence of confirmed cSCC in the intention-to-treat population (defined as all patients randomly assigned), with the primary timepoint of interest being 1 year after randomisation. The study is registered with ISRCTN, ISRCTN74112318, and is now complete.

FINDINGS

Between Feb 26, 2013, and April 25, 2017, 420 patients were randomly assigned to the control (n=210) or screening MRI (n=210) groups. Median age was 74 years (IQR 68 to 79), 222 (53%) of 420 patients had normal alkaline phosphatase, and median prostate-specific antigen concentration was 48 ng/mL (IQR 17 to 162). Screening MRI detected rSCC in 61 (31%) of 200 patients with assessable scans in the intervention group. As of data cutoff (April 23, 2020), at a median follow-up of 22 months (IQR 13 to 31), time to cSCC was not significantly improved with screening (hazard ratio 0·64 [95% CI 0·37 to 1·11]; Gray's test p=0·12). 1-year cSCC rates were 6·7% (95% CI 3·8-10·6; 14 of 210 patients) for the control group and 4·3% (2·1-7·7; nine of 210 patients) for the intervention group (difference -2·4% [95% CI -4·2 to 0·1]). Median time to cSCC was not reached in either group. No serious adverse events were reported within 24 h of screening.

INTERPRETATION

Despite the substantial incidence of rSCC detected in the intervention group, the rate of cSCC in both groups was low at a median of 22 months of follow-up. Routine use of screening MRI and pre-emptive treatment to prevent cSCC is not warranted in patients with asymptomatic castration-resistant prostate cancer with spinal metastasis.

FUNDING

Cancer Research UK.

Effect of the Timing of Surgery on Neurological Recovery for Patients with Incomplete Paraplegia Caused by Metastatic Spinal Cord Compression

Objective

This study aimed to investigate the effect of timing of surgery on neurological recovery for patients with metastatic spinal cord compression (MSCC).

Methods

According to the timing of surgery, 75 patients with incomplete paraplegia caused by MSCC were assigned to 3 groups: within 3 days (group A), between 4 days and 7 days (group B), and after 7 days (group C). T-test, one-way ANOVA, Mann–Whitney U-test, and Chi-square test were used to evaluate the difference in the improvement of American Spinal Injury Association Impairment Scale (AIS) and ambulatory status, the incidence of perioperative complications, surgical site infection, and the length of hospital stay between 3 groups.

Results

Patients with incomplete paraplegia treated in our department had an average of 17.4±1.8 days delayed and most occurred before hospitalization (4.0±0.4 vs 13.2±1.8, P<0.001). There was no significant difference in the AIS improvement between patients with different pre-op AIS. The timing of surgery was significantly correlated with AIS improvement (correlation coefficient=−0.257, P=0.019). Sub-analysis showed that patients who underwent surgery within 7 days (group A and group B) had significantly better AIS improvement compared with group C (improved at least 1 grade, P=0.043; improved more than 1 grade, P=0.039) and the surgery timing was more important for patients with AIS B and C. The timing of surgery was significantly correlated with the length of hospital stay (correlation coefficient=0.335, P=0.003). Patients of group C had the longest length of hospital stay (P=0.002). The incidence of perioperative complications and surgical site infection did not differ significantly between the 3 groups.

Conclusion

Delay surgery was common in incomplete paraplegia patients with MSCC. Patients with AIS B and C who underwent surgery within 7 days had better AIS improvement.

Two Cases of Cranial Nerve Metastasis Treated with Radiotherapy and Chemotherapy in Patients with Lung Adenocarcinoma

The incidence of central nervous system metastasis is known to be high among patients with lung cancer. The frequency of brain metastasis and carcinomatous meningitis during the entire clinical course of non-small cell lung cancer is reported to be about 40% and 5%, respectively. In contrast, the incidence of cranial nerve metastasis is extremely rare, and detailed reports of its clinical course remain limited. Herein, we report 2 patients diagnosed with cranial nerve metastasis of lung adenocarcinoma and treated with radiotherapy and systemic chemotherapy. Both patients had cranial nerve symptoms, and brain magnetic resonance imaging showed cranial nerve enhancement. However, no evidence of carcinomatous meningitis was noted on magnetic resonance imaging and cerebrospinal fluid cytology. Based on these observations, these patients were diagnosed with cranial nerve metastasis of lung adenocarcinoma. Radiotherapy and chemotherapy were performed in both cases. In both cases, neurological symptoms had not worsened and imaging findings did not indicate any deteriorations. Therefore, radiotherapy and systemic chemotherapy should be considered when treating cranial nerve metastasis of lung adenocarcinoma. Early therapeutic intervention may lead to attenuation of the cranial nerve dysfunction resulting from cranial nerve metastasis.

Interventional Techniques for Bone and Musculoskeletal Soft Tissue Tumors: Current Practices and Future Directions - Part I. Ablation

Musculoskeletal (MSK) image-guided oncologic intervention is an established field within radiology. Numerous studies have described its clinical benefits, safety, cost effectiveness, patient satisfaction, and improved quality of life, thereby establishing image-guided oncologic intervention as a preferred pathway in treating patients presenting with specific benign MSK tumors. But there is a paradigm shift on the horizon because these techniques may also support established pillars (surgery, systemic treatment, radiotherapy) in the treatment of malignant MSK tumors. Unlike benign tumors, where they are used as primary therapy lines with curative intent, such interventions can be selected for malignant tumors as adjuvant treatment in painful or unstable bone or soft tissue lesions or as more palliative therapy strategies. Using examples from our clinical practices, we elaborate on the benefits of applying a multidisciplinary approach (traditionally involving MSK radiologists, oncologists, orthopaedic surgeons, microbiologists, pathologists, physiotherapists, and pain management experts), ideally within a sarcoma treatment center to deliver a patient-specific therapy plan and illustrate methods to assess the benefits of this model of care.In this article, we review the current repertoire of ablation techniques, demonstrate why such procedures offer value-based alternatives to conventional treatments of specific tumors, and reflect on future directions. Additionally, we review the advantages and limitations of each technique and offer guidance to improve outcomes.

Quality Improvement Initiative to Enhance Multidisciplinary Management of Malignant Extradural Spinal Cord Compression

PURPOSE

To determine if a quality improvement (QI) initiative could enhance multidisciplinary management of acute malignant extradural spinal cord compression (ESCC) at our institution.

METHODS

The medical records of all 40 patients who received palliative radiotherapy for malignant ESCC from 2015 to 2017 were reviewed to determine the time course of key National Comprehensive Cancer Network guideline-supported workup and management steps. On the basis of the findings, a multidisciplinary group of physician stakeholders developed a clinical pathway to facilitate expedited care. The efficacy of this clinical pathway and the educational content provided to all relevant departments were then evaluated by comparing outcomes with data from a similarly reviewed follow-up cohort of 25 patients from 2018 to 2019.

RESULTS

Patients treated for malignant ESCC after our QI intervention were more likely to undergo magnetic resonance imaging (MRI) of the entire spine (64% v 44%; P = .013) and have a radiation oncology (RO) consultation before surgery (100% v 27%; P = .002). Median time from MRI to RO consultation decreased from 3 to 1 days (P = .03). On subgroup analysis, initial trends toward delays in RO consultation for patients planning for surgery (median, 3 days) or for lack of prior cancer diagnosis (median, 4 days) were reduced to delays of 0 and 1 day, respectively, after the QI intervention. No significant differences were observed in time to surgical consultation or surgery itself.

CONCLUSION

This QI study was able to stimulate better use of diagnostic imaging and earlier involvement of RO in multidisciplinary decision making, suggesting an effective approach to improving multidisciplinary care in other scenarios as well.

Analgesia of percutaneous thermal ablation plus cementoplasty for cancer bone metastases

Background

The purpose of this study was to review recent research related to the analgesic effect of ablation therapy combined with cementoplasty, as well as to identify the duration of analgesic effect and risk for cement leaks.

Methods

A systematic literature search using PubMed, Web of Science, and annual meeting proceedings of the oncology society and other organizations were conducted.

Results

Twelve retrospective studies met the inclusion criteria. Four of the studies included in the review assessed the changes immediately after treatment. Five studies were subjected to analyses of analgesic effect of combined percutaneous thermal ablation and Cementoplasty at 24 weeks after treatment. Incidences of leakage of bone cement during surgery were detected in 4 out of 12 studies. The change of mean pain scores at 1 days, at 1 week, and at 4 weeks, 12 weeks, and 24 weeks after treatment were -3.90 (95% CI: -4.80 to -3.00), -4.55 (95% CI:-5.46 to -3.64), -4.78 (95% CI: -5.70 to -3.86), -5.16 (95% CI: -6.39 to -3.92), and -5.91 (95% CI: -6.63 to -5.19). The relative risk of cement leakage was 0.10 (95% CI: -6.63 to -5.19).

Conclusions

Our systematic review suggested that thermal ablation combined with cementoplasty could be a safe and effective intervention for the management of bone metastases-induced pain.

Delayed presentation to a spine surgeon is the strongest predictor of poor postoperative outcome in patients surgically treated for symptomatic spinal metastases

BACKGROUND CONTEXT

Symptoms associated with spinal metastases are often nonspecific and resemble noncancer-related symptoms. Therefore, patients with spinal metastases are at risk for delayed referral and treatment. Delayed presentation of symptomatic spinal metastases may lead to the development of neurological deficits, often followed by emergency surgery.

PURPOSE

The aim of this cohort study was to analyze the effect of delayed referral and treatment of spinal metastases on clinical outcome.

METHODS

We included all patients surgically treated for spinal metastases at our tertiary care center. Based on the (in)ability to undergo elective surgery, patients were identified as timely treated or delayed. Patient- and tumor-characteristics, surgical variables, and postoperative variables such as complication rate, the ability to return home and length of hospital stay were recorded and compared between the two groups.

RESULTS

Based on the urgency of treatment at admission, 206 patients were identified as timely treated and 98 as delayed. At baseline, the two groups did not differ significantly except for the extent of neurological symptoms. Timely treated patients underwent less invasive procedures (52.9% vs 13.3% percutaneous pedicle screw fixations), had less median blood loss (200cc vs 450cc), shorter median admission time (7 vs 13 days), lower complication rate (26.2% vs 48.0%) and higher chances of being discharged home immediately (82.6% vs 41.1%) compared with delayed patients. Using multivariate regression models these correlations remained present independent of tumor prognosis, preoperative mobility, and American Society of Anesthesiologists-score.

CONCLUSIONS

The delayed presentation of patients with spinal metastases to a spinal surgeon is strongly and independently associated with worse surgical and postoperative outcome parameters. Improvements in referral patterns could potentially lead to more scheduled care, negating the detrimental effects of delay.

Neuropathic Pain in Patients with Cancer

We provide a detailed description of painful neural lesions in hospitalized patients with cancer. A total of 187 consecutive patients with cancer and pain, referred to the pain service of a cancer hospital, were evaluated within 24 hours by two neurologists and followed until discharge or death. Based on history, pain descriptors, physical examination, and radiological and electrophysiological studies, the pain was categorized as neuropathic in 103 patients. The most frequent sites of neurological injury were nerve roots, spinal cord and cauda equina, brachial and lumbosacral plexus, and peripheral nerves. There were no patients with pain caused by injury to the brain. In 93 of these patients, the pain was caused by ongoing neural injury, while, in 10 patients, the neural injury was old and stable. Within these two groups of patients with neuropathic pain, analgesic treatments differed. Prospective studies may determine if categorizing painful neurological injuries in cancer patients based on inferred pathophysiology is useful when deciding among different treatment options.

Assessment and Management of Patients With Metastatic Spinal Cord Compression: A Multidisciplinary Review

Purpose

Metastatic spinal cord compression (MSCC) can be a catastrophic manifestation of advanced cancer that causes immobilizing pain and significant neurologic impairment. Oncologists can protect their patients by having a high index of suspicion for MSCC when patients present with new or worsening back pain before motor, sensory, bowel, or bladder deficits develop. We provide an updated, evidence-based narrative review of the presentation, diagnosis, and treatment of MSCC.

Methods

This narrative review was conducted by searching MEDLINE and Cochrane Database of Systematic Reviews for relevant literature on the presentation, diagnosis, and treatment of patients with MSCC. The article addresses the key elements of MSCC management germane to the medical oncologist, with special attention given to pain and symptom management, decision making with regard to surgery and radiation therapy, the importance of rehabilitative care, and the value of a multidisciplinary approach.

Results

Magnetic resonance imaging of the entire spine is recommended for the diagnosis of MSCC. Treatment includes glucocorticoid therapy, pain management, radiation therapy with or without surgery, and specialized rehabilitation. When formulating a treatment plan, clinicians should consider the patient’s care goals and psychosocial needs.

Conclusion

Prompt diagnosis and treatment of MSCC can reduce pain and prevent irreversible functional loss. Regular collaboration among multidisciplinary providers may streamline care and enhance achievement of treatment goals.

The Impact of a Radiation Oncologist led Oncology Curriculum on Medical Student Knowledge

Medical students at our institution all take a pre-clinical oncology course as well as a clinical radiation oncology didactic session during their clinical curriculum. The objective of this analysis is to demonstrate the impact of the radiation oncology didactic on medical student knowledge of core oncology concepts. All students received a standardized didactic lecture introducing students to core concepts of general oncology and radiation. We administered an 18-question pretest and a posttest examining student knowledge between 2012 and 2015. Changes in student responses between pre-test and post-tests were analyzed to evaluate the effectiveness of the didactic session. Over the course of three years, 319 (64.4%) of 495 students who completed the Radiology block completed both the pre-test and post-test. The average student test grade improved from 62.0% on the pretest to 69.6% on the posttest (p < 0.001). By category, students increased their score from 81.4% to 89.8% (p < 0.001) in general oncology, from 59.9% to 69.9% (p < 0.001) in breast oncology, from 43.0% to 51.0% (p < 0.001) in prostate oncology, and from 71.3% to 75.7% (p = 0.003) in radiation oncology. Students showed increases in knowledge across general oncology, prostate oncology, breast oncology, and radiation oncology.

Malignant Spinal Cord Compression Syndrome as an Initial Presentation of Testicular Cancer

Malignant spinal cord compression syndrome (MSCCS) occurs in 2.5 to 5% of all oncological patients. In 20% of the cases, it is the initial manifestation. This syndrome is a rare event among germ cell tumors (GCT), occurring in only 1.7% of the patients. We present the case of a 24-year-old man who arrived at the emergency department with dysesthesia and paraparesis as well as urinary incontinence. Imaging studies showed an infiltrative lesion in the left testicle, pulmonary and hepatic metastatic disease, and a large retroperitoneal ganglionar conglomerate that infiltrated the spinal cord through the intervertebral foramina of the vertebra level T11 with displacement of the L1 vertebral body. A postoperative biopsy showed a pure embryonal carcinoma. In the initial approach of a young man who presents spinal cord compression, the presence of MSCCS associated with GCT should be considered as a possible cause. A high level of suspicion is required to achieve a timely diagnosis, to grant the patient the best possible outcome.

Palliative pain relief and safety of percutaneous radiofrequency ablation combined with cement injection for bone metastasis

Purpose

To investigate the pain relief effect and safety of percutaneous radiofrequency ablation (RFA) with a multitined electrode combined with cement injection in patients with painful metastatic bone tumors.

Materials and methods

Sixteen patients with 34 osteolytic metastatic lesions were treated with RFA including 4 males and 12 females (age range 54-84). Thirteen patients with spinal metastases received additional cement injection. Medical imaging, a visual analog scale (VAS) and the EORTC QLQ-C30 were performed to evaluate the metastatic lesion, pain and quality of life, respectively, before and after RFA and at follow-ups.

Results

The RFA and/or vertebroplasty with cement injection were successful in all patients (100%). Except for one patient who had cement leakage, no intraprocedural complications occurred. After RFA, severe refractory pain was greatly relieved in all patients, with pretreatment VAS score of 8.1 ± 1.4 significantly reduced to 5.5 ± 1.1 at 24 h, 2.8 ± 0.6 at 1 week and 1.4 ± 0.8 at 6 months (P < 0.01). The EORTC QLQ-C30 scale at 1 month demonstrated significant improvement (P < 0.05) in the physical (P = 0.03) and emotion function (P = 0.003), global health status (P = 0.002), pain (P = 0.001) and insomnia (P = 0.002). The analgesics were reduced after the procedure and stopped 2 months later in all patients, with greatly improved quality of life and no apparent pain. Followed up for 6-12 months, all patients remained alive with no recurrence of pain. Palliative pain relief and safety of percutaneous radiofrequency ablation combined with cement injection for bone metastasis.

Conclusion

RFA with or without bone cement is safe and effective in the palliative treatment of pain caused by metastatic bone tumors.

Emergency Neurologic Life Support: Spinal Cord Compression

There are many causes of acute myelopathy including multiple sclerosis, systemic disease, and acute spinal cord compression (SCC). SCC should be among the first potential causes considered given the significant permanent loss of neurologic function commonly associated with SCC. This impairment can occur over a short period of time, and may be avoided through rapid and acute surgical intervention. Patients with SCC typically present with a combination of motor and sensory dysfunction that has a distribution referable to a spinal level. Bowel and bladder dysfunction and neck or back pain may also be part of the clinical presentation, but are not uniformly present. Because interventions are critically time-sensitive, the recognition and treatment of SCC was chosen as an ENLS protocol.

Epidural and intramedullary spinal metastasis: clinical features and role of fractionated radiotherapy

Metastases involving the spinal epidural space and cord parenchyma are major sources of neurological impairment and decreased quality of life in cancer patients. Herein we review the clinical manifestations, pathophysiology, importance of early diagnosis and initiation of treatment, and role of fractionated radiotherapy of these disorders.

Spinal Cord Injury due to Tumour or Metastasis in Aragón, Northeastern Spain (1991-2008): Incidence, Time Trends, and Neurological Function

Purpose

Understanding the presentation of spinal cord injury (SCI) due to tumours considering population distribution and temporal trends is key to managing SCI health services. This study quantified incidence rates, function scores, and trends of SCI due to tumour or metastasis over an 18-year time period in a defined region in Spain.

Methods

A retrospective cohort study included in-and outpatients with nontraumatic SCI due to tumour or metastasis admitted to a metropolitan hospital in Spain between 1991 and 2008. Main outcome measures were crude and age- and sex-adjusted incidence rates, tumour location and type, distribution by spinal level, neurological level of injury, and impairment ASIA scores.

Results

Primary tumour or metastasis accounted for 32.5% of nontraumatic SCI with an incidence rate of 4.1 per million population. Increasing rates with age and over time were observed. Major pathology groups were intradural-extramedullary masses from which meningiomas and neurinomas accounted for 40%. Lesions were mostly incomplete with predominant ASIA Grade D.

Conclusions

Increasing incidence rates of tumour-related SCI over time in the middle-aged and the elderly suggest a growing need for neurooncology health resources in the future.

Modern approaches to the management of metastatic epidural spinal cord compression

Metastatic epidural spinal cord compression (MESCC) is an oncologic emergency requiring prompt treatment to maximize neurologic function, ambulatory function and local control. Traditionally, options for MESCC included external beam radiation therapy with or without surgery. Surgery has usually been reserved for the patient with optimal performance status, single level MESCC or mechanical instability. Advances in external beam radiation therapy such as the development of stereotactic body radiation therapy have allowed for the delivery of high-dose radiation, allowing for both long-term pain and local control. Surgical advances, such as separation surgery, minimal access spine surgery and percutaneous instrumentation, have decreased surgical morbidity. This review summarizes the latest advances and evidence in MESCC to enable modern management.

Multicenter clinical and imaging evaluation of targeted radiofrequency ablation (t-RFA) and cement augmentation of neoplastic vertebral lesions

Background

Treatment of spinal metastatic lesions by radiofrequency ablation (RFA) before cementation can potentially help in local tumor control and pain relief. This is often limited by access and tumor location. This study reports multicenter clinical and imaging outcomes following targeted RFA (t-RFA) and cement augmentation in neoplastic lesions of the spine.

Material and methods

A retrospective multicenter study of 49 patients with 72 painful vertebral lesions, evaluated for clinical and imaging outcomes following RFA and cement augmentation of spinal metastatic lesions, was undertaken. Visual Analogue Pain score (VAS) and Oswestry Disability Index (ODI) were obtained before and 2–4 weeks after treatment. Pre- and post-procedure imaging examinations including MRI and positron emission tomography (PET) were also evaluated.

Results

Mean ablation time was 3.7±2.5 min (range 0.92–15). Mean VAS scores decreased from 7.9±2.5 pre-procedure to 3.5±2.6 post-procedure (p<0.0001). Mean ODI scores improved from 34.9±18.3 to 21.6±13.8 post-procedure (p<0.0001). Post-contrast MRI resulted in a predictable pattern of decreased tumor volume and an enhancing rim. Metabolically active lesions in pre-procedure PET scans (n=10 levels) showed decreased fluorodeoxyglucose activity after ablation.

Conclusions

t-RFA followed by vertebral augmentation in malignant vertebral lesions resulted in significant pain reduction and functional status improvement, with no major complications. t-RFA permitted access to vertebral lesions and real-time accurate monitoring of the ablation zone temperature. Post-procedure MRI and PET examinations correlated with a favorable tumor response and helped to monitor tumor growth and the timing of adjuvant therapy.

Management of neuro-oncologic emergencies

Patients with brain tumors and systemic malignancies are subject to diverse neurologic complications that require urgent evaluation and treatment. These neurologic conditions are commonly due to the tumor's direct effects on the nervous system, such as cerebral edema, increased intracranial pressure, seizures, spinal cord compression, and leptomeningeal metastases. In addition, neurologic complications can develop as a result of thrombocytopenia, coagulopathy, hyperviscosity syndromes, infection, immune-related disorders, and adverse effects of treatment. Patients may present with typical disease syndromes. However, it is not uncommon for patients to have more subtle, nonlocalizing manifestations, such as alteration of mental status, that could be attributed to other systemic, nonneurologic complications. Furthermore, neurologic complications are at times the initial manifestations of an undiagnosed malignancy. Therefore a high index of suspicion is essential for rapid assessment and management. Timely intervention may prolong survival and improve quality of life. In this chapter, we will discuss the common neuro-oncologic emergencies, including epidemiology, pathophysiology, clinical presentation, diagnosis, and treatment.

Diagnosis and treatment of epidural metastases

Epidural metastases occur in 5% to 10% of cancer patients and represent a neurological emergency. Patients most commonly present with an acute onset of motor weakness, and restoration of neurological function is critically dependent on prompt diagnosis and treatment. This review discusses the clinical, epidemiological, and radiological features associated with epidural metastases and resulting spinal cord compression. Moreover, current treatment paradigms are reviewed. The timely initiation of radiation as well as surgery in select cases is critical for preserving neurological function and achieving local tumor control and pain control. Future studies investigating surgical and radiation treatment for metastatic epidural cord compression are urgently needed. Cancer 2017;123:1106-1114. © 2016 American Cancer Society.

Impact of spinal cord compression from intradural and epidural spinal tumors on perioperative symptoms-implications for surgical decision making

Spinal cord or cauda equina compression (SCC) is an increasing challenge in clinical oncology due to a higher prevalence of long-term cancer survivors. Our aim was to determine the clinical relevance of SCC regarding patient outcome depending on different tumor entities and their anatomical localization (extradural/intradural/intramedullary). We retrospectively analyzed 230 patients surgically treated for SCC. Preoperative status for pain and neurological impairment were correlated to the degree of compression, tumor location, and early as well as short-term follow-up outcome parameters. Interestingly, we did not observe any differences between intradural-extramedullary compared to extradural tumors. Unilaterally localized tumors were likely to present with pain (72.9 %, p < 0.01), whereas concentric growth was associated with motor deficits (41.0 %, p < 0.01, as primary symptom, 49.3 % on admission, p < 0.05). In concentric tumors, the pain pattern was diffuse (40.5 % vs. 17.5 in unilateral disease, p < 0.01), whereas unilateral tumors resulted in localized pain (61.4 % local axial or radicular, p < 0.01). Diffuse pain, patients without a sensory or motor deficit, progressive disease, cervical localization, and a higher degree of stenosis were identified as beneficial for an early improvement in pain (p < 0.05). Notably, 29 % of patients with unchanged pain and 30.8 % with unchanged neurologic function at day 7 postoperative improved during follow-up (p < 0.001). Our data demonstrate that the preoperative tumor anatomy in patients with SCC was closely related to their presenting symptoms and early clinical outcome. The detailed analysis elucidates the biology of SCC and might thereby aid in determining which patients will benefit from surgery.

Surgical management of spinal fractures and neurological involvement in patients with myeloma

INTRODUCTION

Multiple Myeloma (MM) typically involves the spine and causes bone pain, pathological fractures and spinal cord compression with possible consequent neurological deficits. This retrospective study reports the results of surgery on a selected population of patients who underwent surgery for symptomatic spinal myeloma.

MATERIALS AND METHODS

A total of 26 patients who underwent surgery for spinal myeloma with neurological involvement were studied retrospectively. Neurological evaluation was performed according to the Frankel grade. Characteristics of this population, reconstructive techniques and surgery-related complications were reviewed.

RESULTS

The tumours involved the thoracic spine in 13 patients, the lumbar spine in 10 patients, and the cervical spine in three patients. The most common approach was a posterior-only approach (70%), followed by a staged, combined approach (20%), and an anterior-only approach (10%). The mean postoperative survival time was 43 months (range: 8-60 months). A significant improvement in neurological function was observed in the study population after surgery (p=0.001). There were seven early postoperative complications, two late complications and five surgery-related complications.

DISCUSSION

Surgery in selected patients affected by spinal myeloma with neurological involvement is associated with good clinical outcomes and neurological recovery and an acceptable rate of complications. Neurological deficit and segmental instability can be treated sufficiently in most cases by the implementation of a posterior-only approach; however, the final treatment should, when possible, include adjuvant chemotherapy and radiotherapy and rigorous bracing.

Emergency Neurologic Life Support: Spinal Cord Compression

There are many causes of acute myelopathy including multiple sclerosis, systemic disease (SD), and acute spinal cord compression (SCC). SCC should be among the first potential causes considered given the significant permanent loss of neurologic function commonly associated with SCC. This impairment can occur over a short period of time, and may be avoided through rapid and acute surgical intervention. Patients with SCC typically present with a combination of motor and sensory dysfunction that has a distribution referable to a spinal level. Bowel and bladder dysfunction and neck or back pain may also be part of the clinical presentation, but are not uniformly present. Because interventions are critically time-sensitive, the recognition and treatment of SCC was chosen as an ENLS protocol.

Thoracic laminectomy with spinal fixation in a nonambulatory patient with metastatic vertebral tumor from endometrial carcinoma

Vertebral metastasis from endometrial cancer is a rare event and requires emergency treatment at the onset of neurologic symptoms caused by spinal cord compression. We report a case of a metastatic vertebral tumor, according to the International Federation of Gynecology and Obstetrics classification, of stage IVb endometrial cancer with multiple lung metastases. Emergency irradiation to the spinal tumor was conducted as a result of a loss of ambulation. Thoracic laminectomy with spinal fixation was subsequently performed because the patient remained nonambulatory and her neurological function deteriorated. Spinal decompression surgery enabled her to regain the ability to walk. Complete remission was achieved by subsequent pelvic surgery followed by combined chemotherapy consisting of docetaxel and carboplatin. Finally, the patient had no evidence of disease 45 months after the initial treatment. Early recognition and expeditious treatment is crucial for neurological recovery from metastatic spinal cord compression.

Quality of life in patients with malignant spinal cord compression: a review of evidence-based literature

Malignant spinal cord compression (MSCC) is a devastating complication of metastatic cancer. The majority of existing studies focus on treatment guidelines for MSCC, with little emphasis on the impact that MSCC has on quality of life (QoL) for this patient group. This literature review aims to critically appraise available literature focusing on QoL for patients with MSCC. Relevant literature was identified from key electronic databases. A dearth of credible studies representative of the patient population with MSCC was found. Thematic analysis was used as a guide to identify key themes that impact on QoL. Interestingly, patients with MSCC generally report good QoL and low levels of distress in over 50% of cases. However, a significant percentage of patients are distressed. The review concludes that increased awareness and further research into the impact of MSCC is required.

New Magnetic Resonance Imaging Features Predictive for Post-Treatment Ambulatory Function: Imaging Analysis of Metastatic Spinal Cord Compression

STUDY DESIGN

This is a retrospective, single-institute, radiographical study.

OBJECTIVE

The study aimed to determine the correlation of magnetic resonance imaging (MRI) findings observed in metastatic spinal cord compression (MSCC) with post-treatment ambulatory status.

SUMMARY OF BACKGROUND DATA

Previous studies have reported various predictors of ambulatory outcome in patients with MSCC, but the relationship between the MRI features and post-treatment ambulatory function remains to be elucidated.

METHODS

Fifty-six hospitalized patients with MSCC and risk of MSCC were examined using MRI before therapeutic intervention. Circumferential ratio of cord compression (CRCC), clock position of compression, cross-sectional area (CSA), and change in signal intensity of the spinal cord were recorded. Each imaging feature was analyzed statistically regarding unassisted ambulatory status at the time of hospital discharge as the endpoint.

RESULTS

CRCC showed a prognostic value for post-treatment ambulatory function. More than half of CRCC predicted poor functional prognosis with statistical significance. However, the site of cord compression expressed by clock position on axial plane showed no relationship with functional prognosis. CSA of the spinal cord was enlarged in 23% of patients at the level of MSCC, which indicated that cord compression could also be formed by a relative relationship between cord swelling and surrounding mass effect. The said patients showed a better functional outcome. High intensity of the spinal cord on T2-weighted sagittal image was not useful because of lack of inter-rater reliability.

CONCLUSION

CRCC on axial T2 image can guide clinicians to identify cancer patients at risk of paraplegia because of MSCC. More than half of CRCC entails urgent treatment despite preserved ambulatory function. Furthermore, some cases of MSCC accompany increased cord CSA. The measurement is also a useful guide to balance the risk and benefit of systemic steroid therapy. MRI is the key imaging modality in the risk assessment of MSCC.

LEVEL OF EVIDENCE

4.

A review in the treatment of oncologic emergencies

AIM

Oncologic emergencies are often categorized as a group of metabolic abnormalities associated with the diagnosis of cancer or the initiation of chemotherapy for treatment. These syndromes often arise in the acute setting, demanding an accurate knowledge of the associated condition and current treatment. In this review, we evaluate five oncologic emergencies: tumor lysis syndrome, hypercalcemia, hyponatremia, spinal cord compression, and disseminated intravascular coagulation.

SUMMARY

Oncologic emergencies are often diverse in etiology and are often associated with the initiation of chemotherapy. Tumor lysis syndrome presents as severe electrolyte abnormalities that need to be addressed urgently, sometimes prior to initiation of chemotherapy. Hypercalcemia of malignancy is treated with aggressive rehydration, furosemide, and intravenous bisphosphonates. If a patient with cancer presents with normovolemic hyponatremia, syndrome of inappropriate antidiuretic hormone should be suspected. Malignant spinal cord compression happens when cancer cells grow in, or near to, the spine and press on the spinal cord and nerves. This causes swelling and a reduction in the blood supply to the spinal cord and nerve roots. Disseminated intravascular coagulation is characterized by systemic activation of blood coagulation, which results in generation and deposition of fibrin, leading to microvascular thrombi in various organs and contributing to multiple organ dysfunction syndrome.

CONCLUSION

Knowledge of oncology emergencies is critical to the understanding of these emergent syndromes in oncology patients. Each of these disease states requires careful evaluation of the patient's symptoms, monitoring parameters for conditions and supportive care measures and interventions.

The role of radiation therapy in the treatment of metastatic castrate-resistant prostate cancer

In the setting of castrate-resistant prostate cancer, patients present with a variety of symptoms, including bone metastases, spinal cord compression and advanced pelvic disease. Fortunately, a variety of radiotherapeutic options exist for palliation. This article focuses on these options, including both external beam radiotherapy and radiopharmaceuticals.

International survey of the treatment of metastatic spinal cord compression

BACKGROUND AND PURPOSE

Treatment of metastatic spinal cord compression (MSCC) varies significantly. It is useful to understand how radiation oncologists worldwide deal with these challenging and urgent cases. Therefore, a survey of practice patterns of metastatic spinal cord compression was performed among the members of the major radiation oncology organizations in the world to help improve clinical practice.

MATERIAL AND METHODS

The survey questions addressed common clinical issues related to the diagnosis and treatment of spinal cord compression in the context of the available data. The survey of practice pattern in the management of MSCC was performed in 2010. There were a total of 269 survey respondents, and 90% of respondents were from hospital-based practice. Statistical analyses were performed at ASTRO headquarter using Microsoft Excel and SPSS.

RESULTS

The practice pattern of initial diagnostic and clinical evaluation of patients for MSCC was fairly uniform across the continents and countries. Treatment decision was largely based on patient's general condition, overall oncologic status, and concomitant systemic chemotherapy in this survey. EBRT dose and fractionation patterns were determined by considering the estimated survival time, neurological status such as ambulatory status, previous radiation, and radiation treatment volume. Despite of using similar factors in making treatment decision, there was a significant difference in selecting the radiation dose and fractionation scheme. Selection of re-treatment radiation dose also varied and generally below the published tolerance dose.

CONCLUSIONS

Selection of radiation dose and fractionation varied significantly among different continents and countries, while using similar factors to make treatment decision.

A royal college of radiologists national audit of radiotherapy in the treatment of metastatic spinal cord compression and implications for the development of acute oncology services

AIMS

To audit the current use of radiotherapy in UK cancer centres for the treatment of metastatic spinal cord compression against national standards that seek to optimise functional and quality of life outcomes.

MATERIALS AND METHODS

A Royal College of Radiologists prospective national audit of patients treated with radiotherapy in UK cancer centres was carried out over a 3 month period between September and December 2008, with a repeat audit carried out in August 2012.

RESULTS

Five hundred and ninety-six cases were received from 42 cancer centres (74%) in 2008, with data from 323 cases received from 52 (90%) centres in 2012. Ninety-three per cent (358) of patients had a diagnostic magnetic resonance imaging scan carried out within 24 h of referral for radiotherapy in 2008 compared with 205 patients (97%) in 2012. One hundred and eleven (32%) good prognosis patients were discussed with spinal surgeons; only 10 good prognosis patients were recorded as proceeding to surgery in 2008. This improved in 2012, with 94 (41% of good prognosis patients recorded as having been discussed with nine proceeding to surgery). Sixty-nine per cent of paraplegic patients in 2008 received multiple fractions of radiotherapy, which was similar to 2012 when 62% received more than a single fraction. A metastatic spinal cord compression co-ordinator was available in just over 50% of cases (164/323) and was involved in patient management in 26% of cases in 2012.

CONCLUSION

Despite level 1 evidence of the superior functional outcome and survival benefit for surgery, few good prognosis patients were recorded as having been discussed with surgeons and even fewer proceeded to surgery.

Treatment of painful extraspinal bone metastases with percutaneous bipolar radiofrequency under local anesthesia: feasibility and efficacy in twenty-eight cases

PURPOSE

To retrospectively assess the feasibility and efficacy of bipolar radiofrequency ablation (RFA) of extraspinal osseous neoplasms performed under local anesthesia.

METHODS AND MATERIALS

Twenty-eight patients (21 males, 7 females; mean age, 61.2 years) underwent RFA under local anesthesia between 2005 and 2012. All included patients suffered from painful osseous metastases refractory to previous medication; all presented with end-stage neoplasms. RFA was performed under computed tomography (CT) guidance with bipolar radiofrequency probes. All procedures were performed under local anesthesia (lidocaine-ropivacaine) and nitrous oxide ventilation. Intravenous injection of paracetamol was performed throughout the procedure with or without intravenous injection of nalbuphin. Tolerance of procedure was recorded. Pain efficacy was evaluated on visual anologue scale (VAS) scores at day 7, 1 month, and at 6 months after the procedure.

RESULTS

Technical success rate was 100%. The procedure was considered not painful in 4 cases and tolerable in 20 cases. Average procedural time was 23.1 minutes. Mean VAS score prior to RFA was 8.1/10. Significant decrease of pain was noted at day 7 (3.3/10, p<0.001, n=27), 1 month (3.8/10, p<0.001, n=27), and 6 months (4.5/10, p<0.001, n=13). No complications were noted.

CONCLUSION

Bipolar RFA of osseous metastases is a safe and effective treatment for refractory bone metastases. Its feasibility under local anesthesia should broaden the indications.