Outcome of Surgical Treatment for Metastatic Vertebra Bone Tumor in Advanced Lung Cancer

Prognostic factors and outcomes of surgical intervention for patients with spinal metastases secondary to lung cancer: an update systematic review and meta analysis

PURPOSE

Lung cancer is one of the most common malignant tumors. Most patients develop spinal metastases during the course of cancer and suffer skeletal-related events. Currently, no consensus has been reached on the prognostic factors in patients undergoing surgeries. This study aimed to answer two questions: (1) what are the effects of surgical intervention, and (2) what are the factors associated with postoperative survival.

METHODS

Searches were performed on electronic databases including PubMed, Ovid/MEDLINE, Cochrane, and Scopus for articles published before February of 2022, involving the survival factors of patients with spinal metastasis. Multiple data items were considered, such as baseline demographics, surgical details, clinical outcome, and prognostic factors. The analysis was performed in Review Manager (RevMan) 5.5. The prognostic factors of survival were analyzed with univariate and multivariate cox regression analysis.

RESULTS

Finally, 14 studies with 813 patients were identified. Their 6, 12, and 24 months survival rates ranged from 18 to 58%, 18 to 22.4%, and 0 to 58.5%, respectively. The pooled hazard ratio of preoperative ambulatory status and the number of involved vertebrae demonstrated statistical significance, while no significant prognostic effect on the overall survival was found for targeted therapy, visceral metastases, chemotherapy, radiotherapy, or postoperative ambulatory status.

CONCLUSION

Overall, surgical intervention could achieve significant pain relief and neurological function improvements. For patients receiving surgery for spinal metastasis from lung cancer, preoperative ambulatory status and the number of involved vertebrae were significant prognostic factors associated with their survival.

Prognostic Analysis of Spinal Metastasis Secondary to Lung Cancer after Surgeries: A Unicentric, Large-Cohort, Retrospective Study

PURPOSE

Spinal metastases of lung cancer (SMLC) usually have high degree of malignancy and require surgical treatment. However, there are several controversies about the efficacy of surgery. This study aimed to investigate factors predicting prognosis of SMLC after surgery-based comprehensive treatment.

METHODS

A cohort of 112 cases of SMLC who underwent surgical treatment between 2009 and 2020 were retrospectively reviewed and analyzed. The surgical strategies included total en-bloc spondylectomy, debulking surgery, palliative decompression, and vertebral augmentation procedures. The patients were regularly followed-up. Survival analysis was performed, as well as analysis of the patients' neurological recovery, pain relief, and improvement of Karnosky performance score (KPS). Cox regression was used to analyze influencing factors of survival time, and Kaplan-Meier method was performed in survival analysis.

RESULTS

The cohort included 63 males and 49 females, with an average age of 60.6 ± 10.6 years. Median survival time was 16 months. A total of 86.7% of paralysis patients' neurological function recovered and 83.9% of patients with low KPS score (10-40) improved. Surgical method was significantly correlated with improvement of neurological function (p < 0.001) and KPS (p < 0.001). The mean bleeding volume was 502 ml and operative time was 170 min. The survival rates at 3, 6, 12, 24, and 36 months were 92.0%, 80.4%, 63.4%, 63.4%, and 22.6%, respectively. Postoperative Frankel grade (p < 0.001), postoperative KPS score (p = 0.001), and application of molecular targeted drugs (p < 0.001) were significantly correlated with survival time in univariate analysis, while application of molecular targeted drugs was an independent predictor for a longer survival by a multivariate analysis.

CONCLUSION

Surgery-based comprehensive treatment brought a fair outcome, with elongated survival time. Surgery can significantly improve patients' neurological function and physical performance status. Adjuvant targeted therapy is an independent positive factor for patients' survival.

National trends in the surgical management of metastatic lung cancer to the spine using the national inpatient sample database from 2005 to 2014

Optimal management of metastatic lung cancer to the spine (MLCS) incorporates a multidisciplinary approach. With improvements in lung cancer screening andnonsurgical treatment, the role for surgerymay be affected. The objective of this study is to assess trends in the surgical management of MLCS using the National Inpatient Sample (NIS) database. The NIS was queried for patients with MLCS who underwent surgery from 2005 to 2014. The frequencies of spinal decompression alone, spinal stabilization with or without (+/-) decompression, and vertebral augmentation were calculated. Statistical analysis was performed to analyze the effect of patient characteristics on outcomes. The most common procedure performed was vertebral augmentation (10719, 44.3%), followed by spinal stabilization +/- decompression (8634, 35.7%) and then decompression alone (4824, 20.0%). The total number of surgeries remained stable, while the rate of spinal stabilizations increased throughout the study period (p < 0.001). Invasive procedures such as stabilization and decompression were associated with greater costs, length of stay,complications and mortality. Increasingcomorbidity was associated with increased odds of complication, especially in patients undergoing more invasive procedures. In patients with lowpre-operative comorbidity, the type of procedure did not influence the odds of complication. Graded increases in length of stay, cost and mortality were seen with increasing complication rate.The rate of spinal stabilizations increased, which may be due to either increased early detection of disease facilitating use of outpatient vertebral augmentation procedures and/or the recognition that surgical decompression and stabilization are necessary for optimal outcome in the setting of MLCS with neurological deficit.

Spinal metastases from lung cancer: Survival depends only on genotype, neurological and personal status, scarcely of surgical resection

BACKGROUND

For patients with non-small cell lung cancer (NSCLC), the spinal column is the most common site for bone metastasis. Studies that assess survival prognostic factors associated with specific lung spinal metastases (SpM) are weak and required the incorporation of genotype mutations.

METHODS

A prospective French national multicenter database of patients treated for SpM between January 2014 and 2017.818 lung SpM were diagnosed over the course or at the time of diagnosis of 210 consecutive patients with NSCLC.

RESULTS

Median overall survival (OS) time for all patients from the lung SpM event was 5.9 months (SD 0.609). For 122 patients (61%), lung tumor and SpM were diagnosed synchronously. In univariate analysis, good World Health Organisation (WHO) status (p < 0.0001), ambulatory status (Frankel score) (p < 0.0001), the absence of spine epiduritis (p < 0.0001), immunotherapy after SpM diagnosis (p < 0.0001), ALK gene rearrangement (p < 0.0001) and EGFR mutation (p < 0.0001) were associated with longer survival, whereas spine surgery showed no association (0.141). Cox multivariate proportional hazard model identified that EGFR + status (HR: 0.339, 95% CI 0.166-0.693; p = 0.003), good WHO status (p < 0.0001) and good neurological status (Frankel E; p < 0.001 and D; p = 0.018) were associated with higher median OS. Whereas the other factors, including ALK + status, epiduritis and immunotherapy were not independent prognostic factors of survival.

CONCLUSION

Survival in SpM must be prognosticated from general health performance status: clinical (WHO) and neurological (Frankel) as well as the EGFR mutation status. Immunotherapy, surgery and epiduritis have not demonstrated prognostic value. Therefore, surgical prognostic scoring algorithms should incorporate genotype subtypes in NSCLC cancers to adapt surgical treatment.

Association of Pedicle Sign Type with Clinical and Radiological Features in Patients with Symptomatic Spinal Metastases

BACKGROUND

Because of population aging in Japan, the number of cancer diagnoses is increasing rapidly. The pedicle sign is a valuable radiographic indicator of metastases, as the pedicle is the most commonly affected vertebral structure in radiographic assessment. However, few studies have carefully examined the morphological features of pedicle signs. To improve the capacity of medical professionals to diagnose symptomatic spinal metastases, we retrospectively examined the morphological characteristics of pedicle signs and their associations with clinical and radiological features.

METHODS

186 patients with symptomatic spinal metastases who visited our department during the period from January 1, 2011 through December 31, 2017 were enrolled. The pedicle sign was defined as a missing or obscured pedicle on an anteroposterior radiograph. Radiographs were evaluated for pedicles and other vertebrae structures. Clinical and other radiological features were compared in relation to the type of pedicle sign identified.

RESULTS

Pedicle signs were classified as completely disappeared (complete, 26 patients), partially disappeared (partial, 40 patients), or obscured by the osteoblastic background (blastic, 28 patients). Disappearance of both the bone cortex and pedicle was observed in almost half of the patients with complete or partial pedicle signs. The complete pedicle sign was associated with significantly longer survival.

CONCLUSION

Diagnosis of bone metastases requires understanding of pedicle sign types.

Decision Making for the Surgical Treatment of Vertebral Metastases Among Patients with Short Predicted Survival

BACKGROUND

A wide spectrum of treatment choices is proposed for poor-prognosis patients with vertebral metastases. The continuous increase of this population and the propagation of less invasive techniques necessitate further study concerning which patients could benefit from palliative surgery.

METHODS

All patients with a Tokuhashi score ≤8 who had undergone palliative surgical treatment for vertebral metastasis within 4 years were retrospectively reviewed. Demographics, clinical characteristics, and data concerning the disease and the operation were recorded. Patients were assessed on discharge and at 2 months concerning eventual benefit from surgery, based on pain measurements, motor function (Frankel grade), spinal stability assessment, and complications. Statistical analysis was performed to detect possible interrelations.

RESULTS

Eighty-eight patients were reviewed. The average age was 56.5 years. The mean Tokuhashi score was 5.9, and the mean Karnofsky score was 56.4. Thirty-six patients experienced immediate improvement, 12 were lost to follow-up, and 42 were found to have benefited from surgery 2 months later. High Karnofsky score, radicular pain, morphine use, absence of complications, and immediate improvement predicted benefit from surgery.

CONCLUSIONS

Decision making for a patient with poor prognosis concerning eventual surgery for a vertebral metastasis should be based mainly on the patient's clinical presentation; the primary cancer site is of less importance.

Is 1-stage Posterior Corpectomy More Favorable Compared With Decompression With Fusion to Control Thoracic Cord Compression by Metastasis?

STUDY DESIGN

A retrospective comparative study OBJECTIVE:: To compare 1-stage posterior corpectomy to decompression with fusion for the control of thoracic cord compression due to a metastatic tumor.

SUMMARY OF BACKGROUND DATA

Thoracic cord compression by a metastatic tumor can cause back pain, paralysis, and urinary/bowel dysfunction and is generally treated by palliative decompressive surgery. However, no studies have assessed the advantages of 1-stage posterior corpectomy compared with decompression with fusion.

METHODS

We studied 18 patients who underwent surgery for thoracic cord compression due to metastatic tumors between September 2009 and August 2013. Neurological examination was performed preoperatively and postoperatively. Data on operative time, blood loss during surgery, postoperative complications, and survival time were retrospectively retrieved from electronic medical records. Patients were divided into 2 groups based on treatment: decompression and corpectomy (corpectomy group, n=8) and decompression with fusion (decompression-fusion group, n=10). Data were statistically compared between the 2 groups.

RESULTS

The mean age of the patients was 61±12 years. Motor weakness and urinary/bowel dysfunction were observed in 15 and 9 cases, respectively. Five patients, who could walk before surgery, could walk at 1 month following surgery. However, only 3 of the 13 patients who could not walk before surgery regained the ability to walk. No difference was found in the degree of muscle strength recovery between the 2 groups. However, the corpectomy group showed higher blood loss (2200 vs. 710 mL, P=0.037) and longer operative time (281 vs. 217 min, P=0.029) than the decompression-fusion group.

CONCLUSIONS

There is no significant advantage of 1-stage posterior corpectomy over decompression with fusion. Furthermore, more blood loss and longer operative time may increase the risk of postoperative complications following corpectomy. For this reason, 1-stage posterior corpectomy to control thoracic metastasis should be considered with caution.

Effect of Spinal Fixation in Rabbits With Metastatic Tumor Using a Novel Spinal Fusion Model

STUDY DESIGN

An experimental assessment of the impact of spinal stabilization on metastasis growth using a rabbit model.

OBJECTIVE

To investigate the influence of spinal stabilization on the growth of metastatic spinal tumors in rabbits using a novel method of spinal fusion.

SUMMARY OF BACKGROUND DATA

For spinal metastasis patients, gait disturbances caused by back pain or paraplegia correlates with their prognosis. Palliative surgeries are good options for some patients; however, the appropriate timing and method of spinal surgery remains controversial.

METHODS

The biomechanical properties of a novel spinal fixation model with a locking plating system were first examined on the L2-L4 fixed vertebrae of 18 Japanese white rabbits. Biomechanical and radiographic examinations were performed at 0, 4, and 8 weeks as compared with controls. After this, another 31 rabbits were then inoculated with VX2 carcinoma cells into the L3 vertebral body and divided into fixation (N=16) and sham (N=15) groups to assess the impact of spinal stabilization on tumor growth. The time to paraplegia, and tumor cell growth and proliferation were evaluated by rabbit behavior, computed tomography, myelogram, and cell proliferation marker (MIB-1 index).

RESULTS

In the biomechanical loading test, fixed segments showed one eighth of the range of motion and 15 times bending stiffness as compared with controls at each timepoint. No pathologic fractures were observed in the rabbits inoculated with VX2 carcinoma cells before paraplegia, and there was no difference in the time to paraplegia between the fixation and sham groups (26.7 and 28 d, respectively). Similarly, no differences were observed in osteolytic area expansion or tumor cell proliferation (MIB-1 index; 38.1% and 38.0%, respectively).

CONCLUSIONS

Our locking plate fixation of rabbit spines exhibited sufficient biomechanical properties. Spinal fixation had little influence on the growth of the aggressive carcinoma and the time to paraplegia. However, further investigation is needed to determine the influence of spinal stabilization on slow-growing tumors.

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.

Factors Associated with Life Expectancy in Patients with Metastatic Spine Disease from Adenocarcinoma of the Lung

Study Design Retrospective study. Objective Our objective was to identify preoperative prognostic factors associated with survival in patients with spinal metastasis from lung carcinoma. Methods A retrospective analysis of 26 patients diagnosed with lung carcinoma metastatic to the spinal column was performed to determine factors associated with survival. We used 3 months survival as the clinical cutoff for whether surgical intervention should be performed. We analyzed patients who survived less than 3 months compared with those who survived more than 3 months. Demographic, preoperative, operative, and postoperative factors including functional scores were collected for analysis. Results The median survival for all patients in our study was 3.5 months. We found a statistically significant difference between the group that survived less than 3 months and the group that survived greater than 3 months in terms of extrathoracic metastasis, visceral metastasis, and average postoperative modified Rankin score. Conclusion Determining which patients with lung cancer spinal metastases will benefit from surgical intervention is often dictated by the patient's predicted life expectancy. Factors associated with poorer prognosis include age, functional status, visceral metastases, and extrathoracic metastases. Although the prognosis for patients with lung cancer spinal metastases is poor, some patients may experience long-term benefit from surgical intervention.

Is surgery for spine metastasis reasonable in patients older than 60 years?

BACKGROUND

Spinal metastases are common in patients older than 60 years with cancer. Because of the uncertainty of survival and the high incidence of fatal complications, however, chemotherapy and radiotherapy generally have been considered preferable and surgery a treatment of last resort for these patients. Further, the selection criteria indicating surgery and reliable prognostic factors for survival remain controversial.

QUESTIONS/PURPOSES

We therefore assessed surgical complications, postoperative function, and risk factors affecting their overall survival.

METHODS

We retrospectively reviewed 92 patients 60 years or older (range, 60-81 years) who had surgery for spinal metastases. The surgical complications were recorded and a VAS pain score, Frankel grade, and Karnofsky score were obtained. Statistical analyses were performed to identify factors associated with survival. The minimum followup was 6 months (mean, 22 months; range, 6-78 months).

RESULTS

Surgical complications occurred in 21 patients. Pain levels decreased postoperatively in 90% of patients and neurologic function improved in 78%. The Karnofsky status improved in 58 patients giving an improvement rate of 63%. The overall survival rates at 1 year and 3 years were 61% and 35% with a median of 15 months. Primary tumor type and Tokuhashi score independently predicted survival in patients with spinal metastases.

CONCLUSION

Our findings suggest surgery for spinal metastasis can achieve pain relief, neurologic improvement, and restoration of general condition but with a high risk of complications. Primary tumor type and Tokuhashi scoring independently predicted survival in patients with spinal metastases after surgery.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.