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Confavreux CB, Follet H, Mitton D, Pialat JB, Clézardin P. Fracture Risk Evaluation of Bone Metastases: A Burning Issue. Cancers (Basel) 2021; 13:cancers13225711. [PMID: 34830865 PMCID: PMC8616502 DOI: 10.3390/cancers13225711] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/07/2021] [Accepted: 11/10/2021] [Indexed: 11/16/2022] Open
Abstract
Major progress has been achieved to treat cancer patients and survival has improved considerably, even for stage-IV bone metastatic patients. Locomotive health has become a crucial issue for patient autonomy and quality of life. The centerpiece of the reflection lies in the fracture risk evaluation of bone metastasis to guide physician decision regarding physical activity, antiresorptive agent prescription, and local intervention by radiotherapy, surgery, and interventional radiology. A key mandatory step, since bone metastases may be asymptomatic and disseminated throughout the skeleton, is to identify the bone metastasis location by cartography, especially within weight-bearing bones. For every location, the fracture risk evaluation relies on qualitative approaches using imagery and scores such as Mirels and spinal instability neoplastic score (SINS). This approach, however, has important limitations and there is a need to develop new tools for bone metastatic and myeloma fracture risk evaluation. Personalized numerical simulation qCT-based imaging constitutes one of these emerging tools to assess bone tumoral strength and estimate the femoral and vertebral fracture risk. The next generation of numerical simulation and artificial intelligence will take into account multiple loadings to integrate movement and obtain conditions even closer to real-life, in order to guide patient rehabilitation and activity within a personalized-medicine approach.
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Affiliation(s)
- Cyrille B. Confavreux
- Centre Expert des Métastases Osseuses (CEMOS), Département de Rhumatologie, Institut de Cancérologie des Hospices Civils de Lyon (IC-HCL), Hôpital Lyon Sud, Hospices Civils de Lyon, 69310 Pierre Bénite, France
- Université de Lyon, Université Claude Bernard Lyon 1, 69100 Villeurbanne, France; (H.F.); (J.B.P.); (P.C.)
- Institut National de la Santé et de la Recherche Médicale INSERM, LYOS UMR1033, 69008 Lyon, France
- Correspondence:
| | - Helene Follet
- Université de Lyon, Université Claude Bernard Lyon 1, 69100 Villeurbanne, France; (H.F.); (J.B.P.); (P.C.)
- Institut National de la Santé et de la Recherche Médicale INSERM, LYOS UMR1033, 69008 Lyon, France
| | - David Mitton
- Université de Lyon, Université Gustave Eiffel, Université Claude Bernard Lyon 1, LBMC, UMR_T 9406, 69622 Lyon, France;
| | - Jean Baptiste Pialat
- Université de Lyon, Université Claude Bernard Lyon 1, 69100 Villeurbanne, France; (H.F.); (J.B.P.); (P.C.)
- CREATIS, CNRS UMR 5220, INSERM U1294, INSA Lyon, Université Jean Monnet Saint-Etienne, 42000 Saint-Etienne, France
- Service de Radiologie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 69310 Pierre Bénite, France
| | - Philippe Clézardin
- Université de Lyon, Université Claude Bernard Lyon 1, 69100 Villeurbanne, France; (H.F.); (J.B.P.); (P.C.)
- Institut National de la Santé et de la Recherche Médicale INSERM, LYOS UMR1033, 69008 Lyon, France
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Sonatkar J, Kandasubramanian B. Bioactive glass with biocompatible polymers for bone applications. Eur Polym J 2021. [DOI: 10.1016/j.eurpolymj.2021.110801] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Alkalay RN, Adamson R, Miropolsky A, Davis RB, Groff ML, Hackney DB. Large Lytic Defects Produce Kinematic Instability and Loss of Compressive Strength in Human Spines: An in Vitro Study. J Bone Joint Surg Am 2021; 103:887-899. [PMID: 33755638 PMCID: PMC9167060 DOI: 10.2106/jbjs.19.00419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In patients with spinal metastases, kinematic instability is postulated to be a predictor of pathologic vertebral fractures. However, the relationship between this kinematic instability and the loss of spinal strength remains unknown. METHODS Twenty-four 3-level thoracic and lumbar segments from 8 cadaver spines from female donors aged 47 to 69 years were kinematically assessed in axial compression (180 N) and axial compression with a flexion or extension moment (7.5 Nm). Two patterns of lytic defects were mechanically simulated: (1) a vertebral body defect, corresponding to Taneichi model C (n = 13); and (2) the model-C defect plus destruction of the ipsilateral pedicle and facet joint, corresponding to Taneichi model E (n = 11). The kinematic response was retested, and compression strength was measured. Two-way repeated-measures analysis of variance was used to test the effect of each model on the kinematic response of the segment. Multivariable linear regression was used to test the association between the kinematic parameters and compressive strength of the segment. RESULTS Under a flexion moment, and for both models C and E, the lesioned spines exhibited greater flexion range of motion (ROM) and axial translation than the control spines. Both models C and E caused lower extension ROM and greater axial, sagittal, and transverse translation under an extension moment compared with the control spines. Two-way repeated-measures analysis revealed that model E, compared with model C, caused significantly greater changes in extension and torsional ROM under an extension moment, and greater sagittal translation under a flexion moment. For both models C and E, greater differences in flexion ROM and sagittal translation under a flexion moment, and greater differences in extension ROM and in axial and transverse translation under an extension moment, were associated with lower compressive strength of the lesioned spines. CONCLUSIONS Critical spinal lytic defects result in kinematic abnormalities and lower the compressive strength of the spine. CLINICAL RELEVANCE This experimental study demonstrates that lytic foci degrade the kinematic stability and compressive strength of the spine. Understanding the mechanisms for this degradation will help to guide treatment decisions that address inferred instability and fracture risk in patients with metastatic spinal disease.
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Affiliation(s)
- Ron N. Alkalay
- Center for Advanced Orthopedic Studies, Department of Orthopedic Surgery (R.N.A. and R.A.), Division of General Medicine (R.B.D.), and Department of Radiology (D.B.H.), Beth Israel Deaconess Medical Center (BIDMC) and Harvard Medical School, Boston, Massachusetts
| | - Robert Adamson
- Center for Advanced Orthopedic Studies, Department of Orthopedic Surgery (R.N.A. and R.A.), Division of General Medicine (R.B.D.), and Department of Radiology (D.B.H.), Beth Israel Deaconess Medical Center (BIDMC) and Harvard Medical School, Boston, Massachusetts
| | | | - Roger B. Davis
- Center for Advanced Orthopedic Studies, Department of Orthopedic Surgery (R.N.A. and R.A.), Division of General Medicine (R.B.D.), and Department of Radiology (D.B.H.), Beth Israel Deaconess Medical Center (BIDMC) and Harvard Medical School, Boston, Massachusetts
| | - Mike L. Groff
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - David B. Hackney
- Center for Advanced Orthopedic Studies, Department of Orthopedic Surgery (R.N.A. and R.A.), Division of General Medicine (R.B.D.), and Department of Radiology (D.B.H.), Beth Israel Deaconess Medical Center (BIDMC) and Harvard Medical School, Boston, Massachusetts
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Stadelmann MA, Schenk DE, Maquer G, Lenherr C, Buck FM, Bosshardt DD, Hoppe S, Theumann N, Alkalay RN, Zysset PK. Conventional finite element models estimate the strength of metastatic human vertebrae despite alterations of the bone's tissue and structure. Bone 2020; 141:115598. [PMID: 32829037 PMCID: PMC9206866 DOI: 10.1016/j.bone.2020.115598] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 06/05/2020] [Accepted: 08/12/2020] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Pathologic vertebral fractures are a major clinical concern in the management of cancer patients with metastatic spine disease. These fractures are a direct consequence of the effect of bone metastases on the anatomy and structure of the vertebral bone. The goals of this study were twofold. First, we evaluated the effect of lytic, blastic and mixed (both lytic and blastic) metastases on the bone structure, on its material properties, and on the overall vertebral strength. Second, we tested the ability of bone mineral content (BMC) measurements and standard FE methodologies to predict the strength of real metastatic vertebral bodies. METHODS Fifty-seven vertebral bodies from eleven cadaver spines containing lytic, blastic, and mixed metastatic lesions from donors with breast, esophageal, kidney, lung, or prostate cancer were scanned using micro-computed tomography (μCT). Based on radiographic review, twelve vertebrae were selected for nanoindentation testing, while the remaining forty-five vertebrae were used for assessing their compressive strength. The μCT reconstruction was exploited to measure the vertebral BMC and to establish two finite element models. 1) a micro finite element (μFE) model derived at an image resolution of 24.5 μm and 2) homogenized FE (hFE) model derived at a resolution of 0.98 mm. Statistical analyses were conducted to measure the effect of the bone metastases on BV/TV, indentation modulus (Eit), ratio of plastic/total work (WPl/Wtot), and in vitro vertebral strength (Fexp). The predictive value of BMC, μFE stiffness, and hFE strength were evaluated against the in vitro measurements. RESULTS Blastic vertebral bodies exhibit significantly higher BV/TV compared to the mixed (p = 0.0205) and lytic (p = 0.0216) vertebral bodies. No significant differences were found between lytic and mixed vertebrae (p = 0.7584). Blastic bone tissue exhibited a 5.8% lower median Eit (p< 0.001) and a 3.3% lower median Wpl/Wtot (p<0.001) compared to non-involved bone tissue. No significant differences were measured between lytic and non-involved bone tissues. Fexp ranged from 1.9 to 13.8 kN, was strongly associated with hFE strength (R2=0.78, p< 0.001) and moderately associated with BMC (R2=0.66, p< 0.001) and μFE stiffness (R2=0.66, p< 0.001), independently of the lesion type. DISCUSSION Our findings show that tumour-induced osteoblastic metastases lead to slightly, but significantly lower bone tissue properties compared to controls, while osteolytic lesions appear to have a negligible impact. These effects may be attributed to the lower mineralization and woven nature of bone forming in blastic lesions whilst the material properties of bone in osteolytic vertebrae appeared little changed. The moderate association between BMC- and FE-based predictions to fracture strength suggest that vertebral strength is affected by the changes of bone mass induced by the metastatic lesions, rather than altered tissue properties. In a broader context, standard hFE approaches generated from CTs at clinical resolution are robust to the lesion type when predicting vertebral strength. These findings open the door for the development of FE-based prediction tools that overcomes the limitations of BMC in accounting for shape and size of the metastatic lesions. Such tools may help clinicians to decide whether a patient needs the prophylactic fixation of an impending fracture.
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Affiliation(s)
- Marc A Stadelmann
- ARTORG Center for Biomedical Engineering Research, University of Bern, Freiburgstrasse 3, 3010 Bern, Switzerland
| | - Denis E Schenk
- ARTORG Center for Biomedical Engineering Research, University of Bern, Freiburgstrasse 3, 3010 Bern, Switzerland
| | - Ghislain Maquer
- ARTORG Center for Biomedical Engineering Research, University of Bern, Freiburgstrasse 3, 3010 Bern, Switzerland
| | - Christopher Lenherr
- ARTORG Center for Biomedical Engineering Research, University of Bern, Freiburgstrasse 3, 3010 Bern, Switzerland
| | - Florian M Buck
- University of Zurich & MRI Schulthess Clinic, Zurich, Switzerland
| | - Dieter D Bosshardt
- Robert K. Schenk Laboratory of Oral Histology, School of Dental Medicine, University of Bern, Switzerland
| | - Sven Hoppe
- Department of Orthopedic Surgery, Inselspital, Bern University Hospital, Switzerland
| | | | - Ron N Alkalay
- Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
| | - Philippe K Zysset
- ARTORG Center for Biomedical Engineering Research, University of Bern, Freiburgstrasse 3, 3010 Bern, Switzerland.
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Bailey S, Hackney D, Vashishth D, Alkalay RN. The effects of metastatic lesion on the structural determinants of bone: Current clinical and experimental approaches. Bone 2020; 138:115159. [PMID: 31759204 PMCID: PMC7531290 DOI: 10.1016/j.bone.2019.115159] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 10/31/2019] [Accepted: 11/18/2019] [Indexed: 01/30/2023]
Abstract
Metastatic bone disease is incurable with an associated increase in skeletal-related events, particularly a 17-50% risk of pathologic fractures. Current surgical and oncological treatments are palliative, do not reduce overall mortality, and therefore optimal management of adults at risk of pathologic fractures presents an unmet medical need. Plain radiography lacks specificity and may result in unnecessary prophylactic fixation. Radionuclide imaging techniques primarily supply information on the metabolic activity of the tumor or the bone itself. Magnetic resonance imaging and computed tomography provide excellent anatomical and structural information but do not quantitatively assess bone matrix. Research has now shifted to developing unbiased data-driven tools that can predict risk of impending fractures and guide individualized treatment decisions. This review discusses the state-of-the-art in clinical and experimental approaches for prediction of pathologic fractures with bone metastases. Alterations in bone matrix quality are associated with an age-related increase in skeletal fragility but the impact of metastases on the intrinsic material properties of bone is unclear. Engineering-based analyses are non-invasive with the capability to evaluate oncological treatments and predict failure due to the progression of metastasis. The combination of these approaches may improve our understanding of the underlying deterioration in mechanical performance.
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Affiliation(s)
- Stacyann Bailey
- Center for Biotechnology and Interdisciplinary Studies, Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY, United States of America
| | - David Hackney
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA 02215, United States of America
| | - Deepak Vashishth
- Center for Biotechnology and Interdisciplinary Studies, Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY, United States of America
| | - Ron N Alkalay
- Center for Advanced Orthopedic Studies, Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States of America.
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Liang C, Liu G, Liang G, Zheng X, Yin D, Xiao D, Zeng S, Cai H, Chang Y. Healing pattern classification for thoracolumbar burst fractures after posterior short-segment fixation. BMC Musculoskelet Disord 2020; 21:373. [PMID: 32532236 PMCID: PMC7291420 DOI: 10.1186/s12891-020-03386-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 06/01/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Thoracolumbar burst fractures can be treated with posterior short-segment fixation. However, no classification can help to estimate whether the healed vertebral body will have sufficient stability after implant removal. We aimed to develop a Healing Pattern Classification (HPC) to evaluate the stability of the healed vertebra based on cavity size and location. METHODS Fifty-two thoracolumbar burst fracture patients treated with posterior short-segmental fixation without fusion and followed up for an average of 3.2 years were retrospectively studied. The HPC was divided into 4 types: type I - no cavity; type II - a small cavity with or without the violation of one endplate; type III - a large cavity with or without the violation of one endplate; and type IV - a burst cavity with the violation of both endplates or the lateral cortical shell. The intraobserver and interobserver intraclass correlation coefficients (ICCs) of the HPC were assessed. The demographic characteristics and clinical outcomes of the cohort were compared between the stable group (types I and II) and the unstable group (types III and IV). Logistic regression was conducted to evaluate risk factors for unstable healing. RESULTS The intraobserver and interobserver ICCs of the HPC were 0.86 (95% CI = 0.74-0.90) and 0.77 (95% CI = 0.59-0.86), respectively. While the unstable healing group (types III and IV) accounted for 59.6% of the patients, most of these patients were asymptomatic. The preoperative Load Sharing Classification (LSC) comminution score may predict the occurrence of unstable healing (OR = 8.4, 95% CI = 2.4-29.7). CONCLUSIONS A reliable classification for assessing the stability of a healed vertebra was developed. With type I and II healing, the vertebra is considered stable, and the implant can be removed. With type III healing, the vertebra may have healing potential, but the implant should not be removed unless type II healing is achieved. With type IV healing, the vertebra is considered extremely unstable, and instrumentation should be maintained. Assessing the LSC comminution score preoperatively may help to predict unstable healing after surgery.
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Affiliation(s)
- Changxiang Liang
- Spine departement, Orthopedic center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), 510080, No.106, Zhongshan 2nd Road, Guangzhou, Guangdong Province China
| | - Guihua Liu
- Orthopedic department, Huizhou Municipal Central Hospital, Huizhou City, China
| | - Guoyan Liang
- Spine departement, Orthopedic center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), 510080, No.106, Zhongshan 2nd Road, Guangzhou, Guangdong Province China
| | - Xiaoqing Zheng
- Spine departement, Orthopedic center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), 510080, No.106, Zhongshan 2nd Road, Guangzhou, Guangdong Province China
| | - Dong Yin
- Spine departement, Orthopedic center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), 510080, No.106, Zhongshan 2nd Road, Guangzhou, Guangdong Province China
| | - Dan Xiao
- Spine departement, Orthopedic center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), 510080, No.106, Zhongshan 2nd Road, Guangzhou, Guangdong Province China
| | - Shixing Zeng
- Spine departement, Orthopedic center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), 510080, No.106, Zhongshan 2nd Road, Guangzhou, Guangdong Province China
| | - Honghua Cai
- Orthopedic department, Huizhou Municipal Central Hospital, Huizhou City, China
| | - Yunbing Chang
- Spine departement, Orthopedic center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), 510080, No.106, Zhongshan 2nd Road, Guangzhou, Guangdong Province China
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Costa M, Campello LB, Ryan M, Rochester J, Viceconti M, Dall'Ara E. Effect of size and location of simulated lytic lesions on the structural properties of human vertebral bodies, a micro-finite element study. Bone Rep 2020; 12:100257. [PMID: 32551335 PMCID: PMC7292861 DOI: 10.1016/j.bonr.2020.100257] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 01/07/2020] [Accepted: 03/06/2020] [Indexed: 11/25/2022] Open
Abstract
Currently, the Spinal Instability Neoplastic Score system is used in clinics to evaluate the risk of fracture in patients with spinal metastases. This method, however, does not always provide a clear guideline due to the complexity in accounting for the effect of metastatic lesions on vertebral stability. The aim of this study was to use a validated micro Finite Element (microFE) modelling approach to analyse the effect of the size and location of lytic metastases on the mechanical properties of human vertebral bodies. Micro Computed Tomography based microFE models were generated with and without lytic lesions simulated as holes within a human vertebral body. Single and multiple lytic lesions were simulated with four different sizes and in five different locations. Bone was assumed homogenous, isotropic and linear elastic, and each vertebra was loaded in axial compression. It was observed that the size of lytic lesions was linearly related with the reduction in structural properties of the vertebral body (reduction of stiffness between 3% and 30% for lesion volume between 4% and 35%). The location of lytic lesions did not show a clear effect on predicted structural properties. Single or multiple lesions with the same volume provided similar results. Locally, there was a homogeneous distribution of axial principal strains among the models with and without lytic lesions. This study highlights the potential of microFE models to study the effect of lesions on the mechanical properties of the human vertebral body. MicroFE models can show the effect of lytic lesions on vertebral properties. The size of the lesions was more critical than the location of the lesions. Lesions affecting the cortical shell had a larger effect on the local strains. Multiple lesions showed a similar effect to single lesions.
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Affiliation(s)
- M.C. Costa
- Department of Oncology and Metabolism, Mellanby Centre for bone Research, University of Sheffield, UK
- INSIGNEO Institute for in silico Medicine, University of Sheffield, UK
| | | | - M. Ryan
- Department of Oncology and Metabolism, Mellanby Centre for bone Research, University of Sheffield, UK
- INSIGNEO Institute for in silico Medicine, University of Sheffield, UK
| | - J. Rochester
- Academic Unit of Medical Education, Medical School, University of Sheffield, UK
| | - M. Viceconti
- Department of Industrial Engineering, Alma Mater Studiorum - University of Bologna, Italy
- Medical Technology Lab, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - E. Dall'Ara
- Department of Oncology and Metabolism, Mellanby Centre for bone Research, University of Sheffield, UK
- INSIGNEO Institute for in silico Medicine, University of Sheffield, UK
- Corresponding author at: The Pam Liversidge Building, Sir Robert Hadfield Building, Mappin Street, Sheffield S1 3JD, UK.
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Costa M, Eltes P, Lazary A, Varga P, Viceconti M, Dall’Ara E. Biomechanical assessment of vertebrae with lytic metastases with subject-specific finite element models. J Mech Behav Biomed Mater 2019; 98:268-290. [DOI: 10.1016/j.jmbbm.2019.06.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 06/18/2019] [Accepted: 06/27/2019] [Indexed: 12/25/2022]
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Pennington Z, Goodwin ML, Westbroek EM, Cottrill E, Ahmed AK, Sciubba DM. Lactate and cancer: spinal metastases and potential therapeutic targets (part 2). ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:221. [PMID: 31297386 DOI: 10.21037/atm.2019.01.85] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Metastatic spine disease is a heterogeneous clinical condition commonly requiring surgical intervention. Despite this heterogeneity, all cases share the common theme of altered tumor metabolism, characterized by aerobic glycolysis and high lactate production. Here we review the existing literature on lactate metabolism as it pertains to tumor progression, metastasis, and the formation of painful bone lesions. We included articles from the English literature addressing the role of lactate metabolism in the following: (I) primary tumor aggressiveness, (II) local tissue invasion, (III) metastasis formation, and (IV) generation of oncologic pain. We also report current investigations into restoring normal lactate metabolism as a means of impeding tumor growth and the formation of bony metastases. Both in vivo and in vitro experiments suggest that high lactate levels may be necessary for tumor cell growth, as small molecules inhibitors of lactate dehydrogenase (LDH5/LDHA) decrease both the rate of tumor growth and formation of metastases. Additionally, in vitro evidence strongly implicates lactate in tumor cell migration by driving the amoeboid movements of these cells. Acidification of the local bony tissue by excess lactate production activates CGRP+ neurons in the bone marrow and periosteum to generate oncologic bone pain. High lactate may also increase expression of acid sensing receptors in these neurons to generate the neuropathic pain seen in some patients with metastatic disease. Lastly, investigation into lactate-directed therapeutics is still early in development. Initial preclinical trials looking at LDH5/LDHA inhibitors as well as inhibitors of lactate transporters (MCT1) have demonstrated promise, but clinical work has been restricted to a single phase I trial. Lactate appears to play a crucial role in the pathogenesis of metastatic spine disease. Efforts are ongoing to identify small molecules inhibitors of targets in the lactogenic pathway capable of preventing the formation of osseous metastatic disease.
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Affiliation(s)
- Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew L Goodwin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Erick M Westbroek
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ethan Cottrill
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Pennington Z, Ahmed AK, Cottrill E, Westbroek EM, Goodwin ML, Sciubba DM. Intra- and interobserver reliability of the Spinal Instability Neoplastic Score system for instability in spine metastases: a systematic review and meta-analysis. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:218. [PMID: 31297383 DOI: 10.21037/atm.2019.01.65] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Mechanical instability is one of the two main indications for surgical intervention in patients with metastatic spine disease. Since its publication in 2010, the Spinal Instability Neoplastic Score (SINS) has been the most commonly used means of assessing mechanical instability. To prove clinically valuable though, diagnostic tests must demonstrate consistency across measures and across observers. Here we report a systematic review and meta-analysis of all prior reports of intraobserver and interobserver reliability of the SINS score. To identify articles, we queried the PubMed, CINAHL, EMBASE, Cochrane, and Web of Science databases for all full-text English articles reporting interobserver or intraobserver reliability for the SINS score, category, or a domain of the SINS score. Articles reporting confidence intervals for these metrics were then subjected to meta-analysis to identify pooled estimates of reliability. Of 167 unique studies identified, seven met inclusion criteria and were subjected to qualitative review and meta-analysis. Intraobserver reliability for SINS score was found to be near perfect [estimate =0.815; 90% CI (0.661-0.969)] and interobserver reliability was substantial [0.673; (0.227-1.12)]. Intraobserver and interobserver reliability among spine surgeons was significantly better than reliability across all observers (both P<0.0001). Qualitative analysis suggested that increased surgeon experience may be associated with greater intraobserver and interobserver reliability among spine surgeons. On the whole, meta-analysis of the available literature suggests SINS to have good intraobserver and interobserver reliability, giving it the potential to be a valuable guide to the management of patients with spinal metastases. Further research is required to demonstrate that SINS score correlates with the clinical decision to stabilize.
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Affiliation(s)
- Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ethan Cottrill
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Erick M Westbroek
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew L Goodwin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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