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Ferini *G, Palmisciano P, Scalia G, Haider AS, Bin-Alamer O, Sagoo NS, Bozkurt I, Deora H, Priola SM, Aoun SG, Umana GE. The role of radiation therapy in the treatment of spine metastases from hepatocellular carcinoma: a systematic review and meta-analysis. Neurosurg Focus 2022; 53:E12. [DOI: 10.3171/2022.8.focus2255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE
Spine hepatocellular carcinoma (HCC) metastases severely worsen quality of life and prognosis, with the role of radiotherapy being controversial. The authors systematically reviewed the literature on radiotherapy for spine metastatic HCCs.
METHODS
The PubMed, Scopus, Web of Science, and Cochrane databases were searched according to the PRISMA guidelines to include studies of radiotherapy for spine metastatic HCCs. Outcomes, complications, and local control were analyzed with indirect random-effect meta-analyses.
RESULTS
The authors included 12 studies comprising 713 patients. The median time interval from diagnosis of HCC to spine metastases was 12 months (range 0–105 months). Most lesions were thoracic (35.9%) or lumbar (24.7%). Radiotherapy was delivered with conventional external-beam (67.3%) or stereotactic (31.7%) techniques. The median dose was 30.3 Gy (range 12.5–52 Gy) in a median of 5 fractions (range 1–20 fractions). The median biologically effective dose was 44.8 Gy10 (range 14.4–112.5 Gy10). Actuarial rates of postradiotherapy pain relief and radiological response were 87% (95% CI 84%–90%) and 70% (95% CI 65%–75%), respectively. Radiation-related adverse events and vertebral fractures had actuarial rates of 8% (95% CI 5%–11%) and 16% (95% CI 10%–23%), respectively, with fracture rates significantly higher after stereotactic radiotherapy (p = 0.033). Fifty-eight patients (27.6%) had local recurrences after a median of 6.8 months (range 0.1–59 months), with pooled local control rates of 61.6% at 6 months and 40.8% at 12 months, and there were no significant differences based on radiotherapy type (p = 0.068). The median survival was 6 months (range 0.1–62 months), with pooled rates of 52.5% at 6 months and 23.4% at 12 months.
CONCLUSIONS
Radiotherapy in spine metastatic HCCs shows favorable rates of pain relief, radiological responses, and local control. Rates of postradiotherapy vertebral fractures are higher after high-dose stereotactic radiotherapy.
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Affiliation(s)
- *Gianluca Ferini
- Department of Radiation Oncology, REM Radioterapia srl, Viagrande, Catania, Italy
| | | | - Gianluca Scalia
- Department of Neurosurgery, Highly Specialized Hospital of National Importance "Garibaldi," Catania, Italy
| | - Ali S Haider
- Texas A&M University College of Medicine, Houston, Texas
| | - Othman Bin-Alamer
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Navraj S Sagoo
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ismail Bozkurt
- Department of Neurosurgery, Cankiri State Hospital, Cankiri, Turkey
| | - Harsh Deora
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - Stefano M Priola
- Division of Neurosurgery, Health Sciences North, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Salah G Aoun
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas; and
| | - Giuseppe E Umana
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
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Taha MM, Elsharkawy AM, AlBakry A, Ezat M, Alawamry A. Outcome of surgical treatment of hepatocellular carcinoma-derived spinal metastases: Single center experience in Egypt. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Long HY, Huang TY, Xie XY, Long JT, Liu BX. Treatment strategies for hepatocellular carcinoma with extrahepatic metastasis. World J Clin Cases 2021; 9:5754-5768. [PMID: 34368295 PMCID: PMC8316954 DOI: 10.12998/wjcc.v9.i21.5754] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/20/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023] Open
Abstract
Extrahepatic metastasis (EHM) of hepatocellular carcinoma (HCC) has increasingly been seen due to improved survival with effective management of intrahepatic lesions. The presence of EHM indicates an advanced stage of HCC, for which systemic therapy serves as the standard treatment modality. Since the approval of Sorafenib as the first systemic agent in 2007, it took almost a decade to show its efficacy in both first and further lines of setting until the landscape of systemic drugs was finally expanded. Moreover, with inspiring results from immunotherapy trials in HCC, it appears that the introduction of immunotherapy may lead to an evolution in the portfolio of HCC treatment. Although the locoregional approach in the management of EHM is not recommended for advanced-stage HCC, efforts have been made to demonstrate its efficacy in symptom relief and potential benefit for overall survival. This review provides a summary of recent updates of the systemic agents in the treatment of advanced HCC, with an emphasis on aggressive locoregional management of EHM by various treatment modalities.
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Affiliation(s)
- Hai-Yi Long
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, Guangdong Province, China
| | - Tong-Yi Huang
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, Guangdong Province, China
| | - Xiao-Yan Xie
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, Guangdong Province, China
| | - Jian-Ting Long
- Department of Medical Oncology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, Guangdong Province, China
| | - Bao-Xian Liu
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, Guangdong Province, China
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4
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Uei H, Tokuhashi Y. Prognostic scoring system for metastatic spine tumors derived from hepatocellular carcinoma. J Orthop Surg (Hong Kong) 2020; 28:2309499019899167. [PMID: 32114893 DOI: 10.1177/2309499019899167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE The prognosis of hepatocellular carcinoma (HCC) has recently improved, and so clinicians have greater opportunity to treat HCC-derived spinal metastases. Therefore, predicting life expectancy is important for determining the optimal treatment strategy for such tumors. This study aimed to investigate the prognostic factors for HCC-derived metastatic spine tumors and to develop a scoring system for predicting life expectancy in such cases. METHODS The posttreatment survival time and factors that might influence it were investigated in 62 patients with HCC-derived metastatic spine tumors who were treated at our department (surgery: 27 patients and conservative treatment: 35 patients), and a prognostic scoring system for predicting life expectancy was developed by combining the factors that significantly influenced survival. RESULTS In the univariate analyses, sex, the patient's general condition, the presence/absence of major internal organ metastasis, the total revised Tokuhashi score, the serum albumin level, Child-Pugh class, spinal surgery, and bone-modifying agent (BMA) treatment were found to influence the posttreatment survival time. These factors were subjected to multivariate analysis, and a novel scoring system for predicting life expectancy based on the patient's general condition, the serum albumin level (or Child-Pugh class), and BMA treatment was developed. In the retrospective analysis, the concordance rate between the patients' life expectancy and actual survival times was 90.3%. CONCLUSION The patient's general condition, the serum albumin level (or Child-Pugh class), and BMA treatment influenced the posttreatment survival times of patients with HCC-derived metastatic spine tumors. A prognostic scoring system based on these factors was proposed.
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Affiliation(s)
- Hiroshi Uei
- Department of Orthopaedic Surgery, School of Medicine, Nihon University, Tokyo, Japan
| | - Yasuaki Tokuhashi
- Department of Orthopaedic Surgery, School of Medicine, Nihon University, Tokyo, Japan
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5
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Hu J, Hu C. Thoracic vertebral metastasis from progressive hepatocellular carcinoma following liver transplantation combined with resection of mesenteric and colonic metastases: A case report. Medicine (Baltimore) 2020; 99:e22937. [PMID: 33126359 PMCID: PMC7598842 DOI: 10.1097/md.0000000000022937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Surgical treatment of spinal hepatocellular carcinoma metastasis after Liver transplantation (LT) is a clinical challenge. We herein report the clinical outcomes of the first case of a patient with T11 from hepatocellular carcinoma metastasis after systemic chemotherapy following LT combined with mesenteric resection and colectomy, who was successfully treated with En Bloc spondylectomy. PATIENT CONCERNS The patient with HCC was a 40-year-old man, who had received LT combined with mesenteric resection and colectomy 15 months before. His main symptom was progressive back pain because of T11 metastasis. PET examinations showed a solitary metastasis at T11 without recurrence in the liver and metastasis in the other organs. DIAGNOSIS The patient was diagnosed with the T11 vertebra HCC metastasis after LT combined with resection of HCC mesenteric metastasis and colon metastasis. INTERVENTIONS Five cycles of systemic chemotherapy following LT were performed for preventing HCC metastases. However, the right abdominal wall metastasis was found 9 months after LT, followed by T11 metastases thereafter. Immediate resection of the right abdominal wall metastasis was achieved. En Bloc spondylectomy of T11 vertebra was chosen as a treatment for metastasis to T11. After T11 surgery, the patient showed obvious pain relief. However, At 3 months after T11 surgery, a grafted liver metastasis and multiple nodules metastasis in the greater omentum region were revealed with CT imaging, At 5 months after T11 surgery, multiple lung metastases were discovered by MRI. The patient was performed 5 cycles of chemotherapy, 3 times of infusion of iodine [131I] meximab and 3 times of TACE after T11 surgery. Multiple bone metastases were treated with radiotherapy. OUTCOMES The patient died 29 months after LT combined with mesenteric resection and colectomy because of recurrence in the liver and metastasis in the lung. LESSONS En Bloc spondylectomy may be a therapeutic choice for patients with progression after systemic chemotherapy for the solitary spinal metastases after LT combined with mesenteric resection and colectomy, which has a survival benefit without local recurrence at the surgical site. immunosuppressant after LT may result in worse immune function, which leads to HCC more prone to recurrence and bone metastasis.
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Affiliation(s)
- Jingen Hu
- Department of Orthopedics, The First Affiliated Hospital, School of Medicine, Zhejiang University
| | - Caibao Hu
- Intensive Care Unit, Zhejiang Hospital, Hangzhou, Zhejiang, China
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6
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Hu JG, Lu Y, Lin XJ. En Bloc lumpectomy of T12 vertebra for progressive hepatocellular carcinoma metastases following liver transplantation: A case report. Medicine (Baltimore) 2020; 99:e18756. [PMID: 31914098 PMCID: PMC6959957 DOI: 10.1097/md.0000000000018756] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
RATIONALE Liver transplantation (LT) is the preferred surgical option for the treatment of early hepatocellular carcinoma (HCC). In contrast, surgical treatment of progressive HCC metastasized to the spine following LT constitutes a considerable challenge. Here, we report the first case of progressive HCC metastasized to the T12 vertebra after local radiotherapy, treated successfully with en bloc lumpectomy following LT for HCC. PATIENT CONCERNS A 40-year-old man who had undergone LT for the treatment of HCC 2 months prior presented to our clinic with symptoms of progressive back pain. Magnetic resonance imagining (MRI) and positron emission tomography (PET) examinations showed a solitary metastasis at T12 without recurrence in the liver or metastasis to other organs. DIAGNOSES The patient was diagnosed with HCC metastasized to the T12 vertebra after liver transplantation. INTERVENTIONS Local radiation therapy of the T12 vertebra was performed; however, the lesion continued to grow one month after irradiation. Accordingly, the patient was treated with en bloc lumpectomy of the T12 vertebra. After surgery, the patient reported significant pain relief. At 11 months post-surgery, a C4 metastasis with spinal cord compression was revealed by MRI. Multiple grafted liver metastases were also detected by ultrasound along with several lung metastases, which were discovered by X-ray. The patient was treated with a pedicle screw system and a mesh cage filled with frozen autografts for C4 metastasis. OUTCOMES The patient died 15 months after liver transplantation due to recurrence in the liver and metastasis to the lung. LESSONS En bloc lumpectomy may be a viable therapeutic option for patients with progressive solitary spinal metastases after LT refractory to radiotherapy. Use of immunosuppressive therapy after LT may significantly inhibit immune function, making patients more susceptible to HCC recurrence and bone metastasis.
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Jung JM, Chung CK, Kim CH, Yang SH. Minimally Invasive Surgery without Decompression for Hepatocellular Carcinoma Spinal Metastasis with Epidural Spinal Cord Compression Grade 2. J Korean Neurosurg Soc 2019; 62:467-475. [PMID: 30919607 PMCID: PMC6616991 DOI: 10.3340/jkns.2018.0199] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 11/20/2018] [Indexed: 11/27/2022] Open
Abstract
Objective There is a lack of knowledge regarding whether decompression is necessary in treating patients with epidural spinal cord compression (ESCC) grade 2. The purpose of this study was to compare the outcomes of minimally invasive surgery (MIS) without decompression and conventional open surgery (palliative laminectomy) for patients with hepatocellular carcinoma (HCC) spinal metastasis of ESCC grade 2.
Methods Patients with HCC spinal metastasis requiring surgery were retrospectively reviewed. Patients with ESCC grade 2, medically intractable mechanical back pain, a Nurick grade better than 3, 3–6 months of life expectancy, Tomita score ≥5, and Spinal Instability Neoplastic Score ≥7 were included. Patients with neurological deficits, other systemic illnesses and less than 1 month of life expectancy were excluded. Thirty patients were included in the study, including 17 in the open surgery group (until 2008) and 13 in the MIS group (since 2009).
Results The MIS group had a significantly shorter operative time (94.2±48.2 minutes vs. 162.9±52.3 minutes, p=0.001), less blood loss (140.0±182.9 mL vs. 1534.4±1484.2 mL, p=0.002), and less post-operative intensive care unit transfer (one patient vs. eight patients, p=0.042) than the open surgery group. The visual analogue scale for back pain at 3 months post-operation was significantly improved in the MIS group than in the open surgery group (3.0±1.2 vs. 4.3±1.2, p=0.042). The MIS group had longer ambulation time (183±33 days vs. 166±36 days) and survival time (216±38 days vs. 204±43 days) than the open surgery group without significant difference (p=0.814 and 0.959, respectively).
Conclusion MIS without decompression would be a good choice for patients with HCC spinal metastasis of ESCC grade 2, especially those with limited prognosis, mechanical instability and no neurologic deficit.
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Affiliation(s)
- Jong-Myung Jung
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea.,Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul, Korea.,Clinical Research Institute, Seoul National University Hospital, Seoul, Korea.,Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Korea
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea.,Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul, Korea.,Clinical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Seung Heon Yang
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea.,Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul, Korea.,Clinical Research Institute, Seoul National University Hospital, Seoul, Korea
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8
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Ohashi M, Hirano T, Watanabe K, Hasegawa K, Ito T, Katsumi K, Shoji H, Mizouchi T, Takahashi I, Homma T, Endo N. En Bloc Spondylectomy for Spinal Metastases: Detailed Oncological Outcomes at a Minimum of 2 Years after Surgery. Asian Spine J 2018; 13:296-304. [PMID: 30481978 PMCID: PMC6454284 DOI: 10.31616/asj.2018.0145] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 08/12/2018] [Indexed: 01/06/2023] Open
Abstract
Study Design Retrospective case series. Purpose To investigate the oncological outcomes, including distant relapse, after en bloc spondylectomy (EBS) for spinal metastases in patients with a minimum of 2-year follow-up. Overview of Literature Although EBS has been reported to be locally curative and extend survival in select patients with spinal metastases, detailed reports regarding the control of distant relapse after EBS are lacking. Methods We conducted a retrospective review of 18 consecutive patients (median age at EBS, 62 years; range, 40–77 years) who underwent EBS for spinal metastases between 1991 and 2015. The primary cancer sites included the kidney (n=7), thyroid (n=4), liver (n=3), and other locations (n=4). Survival rates were estimated using the Kaplan–Meier method, and groups were compared using the log-rank method. Results The median operative time and intraoperative blood loss were 767.5 minutes and 2,375 g, respectively. Twelve patients (66.7%) experienced perioperative complications. Five patients (27.8%) experienced local recurrence of the tumor at a median of 12.5 months after EBS, four of which had a positive resection margin status. Thirteen patients (72.2%) experienced distant relapse at a median of 21 months after EBS. The estimated median survival period after distant relapse was 20 months (95% confidence interval, 0.71–39.29 months). No association was found between resection margin status and distant relapse. Overall, the 2-year, 5-year, and 10-year survival rates after EBS were 72.2%, 48.8%, and 27.1%, respectively. Importantly, the era in which EBS was performed did not impact the oncological outcomes. Conclusions Our results suggest that EBS by itself, even if margin-free, cannot prevent further dissemination, which occurred in >70% of patients at a median of 21 months after EBS. These results should be considered and conveyed to patients for clinical decision-making.
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Affiliation(s)
- Masayuki Ohashi
- Department of Orthopedic Surgery, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Toru Hirano
- Department of Orthopedic Surgery, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Kei Watanabe
- Department of Orthopedic Surgery, Niigata University Medical and Dental Hospital, Niigata, Japan
| | | | - Takui Ito
- Department of Orthopedic Surgery, Niigata City General Hospital, Niigata, Japan
| | - Keiichi Katsumi
- Department of Orthopedic Surgery, Uonuma Kikan Hospital, Niigata, Japan
| | - Hirokazu Shoji
- Department of Orthopedic Surgery, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Tatsuki Mizouchi
- Department of Orthopedic Surgery, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Ikuko Takahashi
- Department of Orthopedic Surgery, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Takao Homma
- Niigata Spine Surgery Center, Niigata, Japan
| | - Naoto Endo
- Department of Orthopedic Surgery, Niigata University Medical and Dental Hospital, Niigata, Japan
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Uei H, Tokuhashi Y, Maseda M, Nakahashi M, Sawada H, Matsumoto K, Miyakata Y, Soma H. Surgical management of coincidental metastases to upper cervical spine and skull from hepatocellular carcinoma: a case report. J Int Med Res 2018; 46:4852-4859. [PMID: 30282498 PMCID: PMC6259363 DOI: 10.1177/0300060518800875] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Metastases to the skull or upper cervical spine from hepatocellular carcinoma (HCC) are very rare. We herein report a unique case of two-site surgery for both skull and upper cervical spine metastases from HCC. The patient was a 64-year-old man with cervical pain. Computed tomography (CT) revealed osteolytic change related to metastatic cervical spine and occipital bone tumors. Two-stage surgery involving posterior occipitocervical fusion and occipital bone tumor resection was performed. The patient’s pain decreased in severity, and postoperative radiotherapy and chemotherapy could be conducted. The postoperative course was favorable, and the patient exhibited improvement in his activities of daily living. Neither cervical spine X-ray examination nor CT showed any instrumentation failure, such as screw loosening, before the patient died of liver failure 13 months after surgery. Patients with both skull and upper cervical spine metastases from liver cancer may have a markedly unfavorable prognosis. Even in these patients, however, surgery as an aggressive palliative treatment may prolong the survival period or maintain the quality of life as long as the patient’s general condition permits.
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Affiliation(s)
- Hiroshi Uei
- Department of Orthopaedic Surgery, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Yasuaki Tokuhashi
- Department of Orthopaedic Surgery, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Masafumi Maseda
- Department of Orthopaedic Surgery, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Masahiro Nakahashi
- Department of Orthopaedic Surgery, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Hirokatsu Sawada
- Department of Orthopaedic Surgery, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Koji Matsumoto
- Department of Orthopaedic Surgery, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Yukihiro Miyakata
- Department of Orthopaedic Surgery, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Hirotoki Soma
- Department of Orthopaedic Surgery, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
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10
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Rim CH, Choi C, Choi J, Seong J. Establishment of a Disease-Specific Graded Prognostic Assessment for Hepatocellular Carcinoma Patients with Spinal Metastasis. Gut Liver 2018; 11:535-542. [PMID: 28506029 PMCID: PMC5491089 DOI: 10.5009/gnl16486] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 11/15/2016] [Accepted: 12/05/2016] [Indexed: 12/19/2022] Open
Abstract
Background/Aims Hepatocellular carcinoma (HCC) patients with spinal metastasis (SM) show heterogeneous lengths of survival. In this study, we develop and propose a graded prognostic assessment for HCC patients with SM (HCC-SM GPA). Methods We previously reported the outcomes of 192 HCC patients with SM who received radiotherapy from April 1992 to February 2012. Prognostic factors that significantly affected survival in that study were used to establish the HCC-SM GPA. Validation was performed using an independent cohort of 63 patients recruited from September 2011 to March 2016. Results We developed the HCC-SM GPA using the following factors: Eastern Cooperative Oncology Group performance status (0–2, 0 point; 3–4, 1 point), controlled primary HCC (yes, 0 point; no, 2 points), and extrahepatic metastases other than bone (no, 0 point; yes, 1 point). Patients were stratified into low (GPA=0), intermediate (GPA=1 to 2), and high risk (GPA=3 to 4). When applied to the validation cohort, the HCC-SM GPA determined median survival durations of 13.6, 4.8, and 2.6 months and 1-year overall survival rates of 58.3%, 17.8%, and 7.3% for the low-, intermediate-, and high-risk patient groups, respectively (p<0.001). Conclusions Our newly proposed HCC-SM GPA successfully predicted survival outcomes.
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Affiliation(s)
- Chai Hong Rim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Chiwhan Choi
- Department of Radiation Oncology, St. Carollo General Hospital, Suncheon, Korea
| | - Jinhyun Choi
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jinsil Seong
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
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11
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Uei H, Tokuhashi Y, Maseda M. Treatment outcomes of patients with spinal metastases derived from hepatocellular carcinoma. Int J Clin Oncol 2018; 23:886-893. [PMID: 29654428 DOI: 10.1007/s10147-018-1277-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 04/08/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND The prognosis of hepatocellular carcinoma (HCC) used to be poor, but it has recently improved, which has meant that clinicians have greater opportunity to treat spinal metastases and the associated epidural spinal cord compression. However, there have been few systematic functional studies about HCC-derived spinal metastases. The treatment outcomes of surgical treatment for HCC-derived metastatic spinal tumors were investigated. METHODS The post-treatment survival period and pain, paralysis, and disturbance of activities of daily living (ADL) were investigated in 60 patients (surgery 25, conservative treatment 35). RESULTS The mean post-treatment survival period was 7.4 ± 8.2 months (range 0.3-36 months). Univariate analysis indicated that the following factors influenced survival: the patient's general condition, presence/absence of major internal organ metastasis, serum albumin level, Child-Pugh classification, surgical treatment for spinal metastasis, and bone-modifying agent treatment. In the multivariate analysis of these 6 items, 3 significant factors were extracted: the patient's general condition, the serum albumin level, and bone-modifying agent treatment. Pain significantly improved in both groups (p < 0.001). Paralysis did not change significantly in the surgical group (p = 0.575), but it was significantly aggravated in the conservative treatment group (p = 0.047). The ADL abilities of the surgical group improved significantly (p < 0.001). CONCLUSION Most patients exhibited poor survival. In the conservative treatment group, paralysis was significantly aggravated, and little improvement was seen in the patients' ADL abilities. In the surgical group, the patients' ADL abilities improved significantly, but their paralysis did not. Therefore, surgery should be actively performed for HCC-derived spinal metastasis whenever it is indicated.
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Affiliation(s)
- Hiroshi Uei
- Department of Orthopaedic Surgery, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Yasuaki Tokuhashi
- Department of Orthopaedic Surgery, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Masafumi Maseda
- Department of Orthopaedic Surgery, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
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12
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Ohashi M, Hirano T, Watanabe K, Katsumi K, Shoji H, Sano A, Tashi H, Takahashi I, Wakasugi M, Shibuya Y, Endo N. Preoperative prediction for regaining ambulatory ability in paretic non-ambulatory patients with metastatic spinal cord compression. Spinal Cord 2016; 55:447-453. [PMID: 27752060 DOI: 10.1038/sc.2016.145] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 07/28/2016] [Accepted: 09/02/2016] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Retrospective multicenter study. OBJECTIVES To analyze the predictive factors for postoperative ambulatory recovery in paretic non-ambulatory patients with metastatic spinal cord compression (MSCC). SETTING Japan. METHODS Eighty-two consecutive patients (74.4% men; mean age, 66.2 years) who could not walk before surgery due to cervical or thoracic MSCC and underwent posterior decompressive surgery between 2003 and 2014 were included. Patients were divided into two groups according to ambulatory status at 6 weeks after surgery: recovery (group R) and non-recovery (group NR). To evaluate the speed of progression of motor deficits, we assessed the period from onset of neurological symptoms to gait inability (T1). RESULTS Fifty patients (61.0%) regained the ability to walk (group R). The period of T1 demonstrated a positive correlation with probability of ambulatory recovery (P=0.00; Kendall's tau-b=0.38), and a receiver operating characteristic curve analysis showed that the cutoff value of T1 was 5 days (area under the curve=0.72; P=0.001). In multivariate analysis, <6 days of T1 was one of the independent risk factors for failing to regain ambulatory ability (odds ratio, 8.74; P=0.00). CONCLUSIONS The speed of progression of motor deficits can independently and powerfully predict the chance of postoperative ambulatory recovery as well as previously identified predictors. Since information about the speed of progression can be obtained easily by interviewing patients or family members, even if the patient is in an urgent state, our results will be helpful in clinical decision-making.
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Affiliation(s)
- M Ohashi
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - T Hirano
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - K Watanabe
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - K Katsumi
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - H Shoji
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - A Sano
- Department of Orthopedic Surgery, Niigata Prefectural Shibata Hospital, Shibata, Japan
| | - H Tashi
- Department of Orthopedic Surgery, Niigata Prefectural Central Hospital, Joetsu, Japan
| | - I Takahashi
- Department of Orthopedic Surgery, Niigata City General Hospital, Niigata, Japan
| | - M Wakasugi
- Department of Orthopedic Surgery, Niigata Prefectural Central Hospital, Joetsu, Japan
| | - Y Shibuya
- Department of Orthopedic Surgery, Tsuruoka Municipal Hospital, Tsuruoka, Japan
| | - N Endo
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Goodwin CR, Yanamadala V, Ruiz-Valls A, Abu-Bonsrah N, Shankar G, Sankey EW, Boone C, Clarke MJ, Bilsky M, Laufer I, Fisher C, Shin JH, Sciubba DM. A Systematic Review of Metastatic Hepatocellular Carcinoma to the Spine. World Neurosurg 2016; 91:510-517.e4. [PMID: 27090971 PMCID: PMC5586495 DOI: 10.1016/j.wneu.2016.04.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 04/06/2016] [Accepted: 04/06/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) frequently metastasizes to the spine. The impact of medical and/or surgical intervention on overall survival has been examined in a limited number of clinical studies, and herein we systematically review these data. METHODS We performed a literature review using PubMed, Embase, CINAHL, and Web of Science to identify articles that reported survival, clinical outcomes, and/or prognostic factors associated with patients diagnosed with spinal metastases. The methodologic quality of each review was assessed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses tool. RESULTS There were 26 articles (152 patients) that met the inclusion criteria and were treated with either surgery, radiotherapy, chemotherapy, and/or observation. There were 3 retrospective cohort studies, 17 case reports, 5 case series, and 1 longitudinal observational study. Of the patients with known overall survival after diagnosis of spinal metastasis, survival at 3 months, 6 months, 1 year, 2 years, and 5 years was 95.2%, 83.0%, 28.6%, 2.0%, and 1.4%, respectively. The median survival after diagnosis of the metastasis was 0.7 months in the patients who received no treatment, 7 months in the patients treated with surgical intervention alone, 6 months for patients who received chemotherapy and/or radiation, and 13.5 months in the patients treated with a combination of surgery and medical management. All other clinical or prognostic parameters were of low or insufficient strength. CONCLUSIONS Patients diagnosed with HCC spinal metastasis have a 10.6-month overall survival. Further analysis of patients in prospective controlled trials will be essential to the development of treatment algorithms for these patients in the future.
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Affiliation(s)
- C. Rory Goodwin
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vijay Yanamadala
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Alejandro Ruiz-Valls
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nancy Abu-Bonsrah
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ganesh Shankar
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Eric W. Sankey
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christine Boone
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Mark Bilsky
- Department of Neurological Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Ilya Laufer
- Department of Neurological Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Charles Fisher
- Department of Orthopaedics, Division of Spine, University of British Columbia and Vancouver General Hospital, Vancouver, BC, Canada
| | - John H. Shin
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel M. Sciubba
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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14
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Lee MH, Lee SH, Kim ES, Eoh W, Chung SS, Lee CS. Survival-Related Factors of Spinal Metastasis with Hepatocellular Carcinoma in Current Surgical Treatment Modalities : A Single Institute Experience. J Korean Neurosurg Soc 2015; 58:448-53. [PMID: 26713145 PMCID: PMC4688314 DOI: 10.3340/jkns.2015.58.5.448] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 07/07/2015] [Accepted: 07/08/2015] [Indexed: 11/27/2022] Open
Abstract
Objective Recently, the survival of patients with hepatocellular carcinoma (HCC) has been prolonged with improvements in various diagnostic tools and medical treatment modalities. Consequently, spine metastases from HCC are being diagnosed more frequently. The accurate prediction of prognosis plays a critical role in determining a patient's treatment plan, including surgery for patients with spinal metastases of HCC. We investigated the clinical features, surgical outcomes, and prognostic factors of HCC presenting with spine metastases, in patients who underwent surgery. Methods A retrospective review was conducted on 33 HCC patients who underwent 36 operations (three patients underwent surgical treatment twice) from February 2006 to December 2013. The median age of the patients was 56 years old (range, 28 to 71; male : female=30 : 3). Results Overall survival was not correlated with age, sex, level of metastases, preoperative Child-Pugh classification, preoperative ambulatory function, preoperative radiotherapy, type of operation, administration of Sorafenib, or the Tokuhashi scoring system. Only the Tomita scoring system was shown to be an independent prognostic factor for overall survival. Comparing the Child-Pugh classification and ambulatory ability, there were no statistically differences between patients pre- and post-operatively. Conclusion The Tomita scoring system represents a practicable and highly predictive prognostic tool. Even though surgical intervention may not restore ambulatory function, it should be considered to prevent deterioration of the patient's overall condition. Additionally, aggressive management may be needed if there is any ambulatory ability remaining.
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Affiliation(s)
- Min Ho Lee
- Department of Neurosurgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sun-Ho Lee
- Department of Neurosurgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun-Sang Kim
- Department of Neurosurgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Whan Eoh
- Department of Neurosurgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung-Soo Chung
- Department of Orthopedic Surgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chong-Suh Lee
- Department of Orthopedic Surgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Successful Total En Bloc Spondylectomy of T7 Vertebra for Hepatocellular Carcinoma Metastasis After Living Donor Liver Transplantation. Spine (Phila Pa 1976) 2015; 40:E944-7. [PMID: 25893346 DOI: 10.1097/brs.0000000000000930] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case report. OBJECTIVE We report a patient who was successfully treated with total en bloc spondylectomy (TES) for T7 metastasis after living donor liver transplantation for hepatocellular carcinoma (HCC). SUMMARY OF BACKGROUND DATA Spinal metastasis from HCC has a poor prognosis. There are only a few studies on surgical outcomes of spinal metastasis from HCC. Because of the high surgical morbidity and short life expectancy in patients with HCC with spinal metastasis, TES is not considered in these patients, although several studies have reported satisfactory results for TES for some types of metastatic spinal tumors. Liver transplantation (LT) is the curative treatment option for early HCC. However, the recurrence of HCC is a possible problem after LT, although no reports on surgery for spinal metastasis following LT for HCC have been published. We report on the first case of a patient who was successfully treated with TES for T7 metastasis after living donor LT for HCC. METHODS The patient was a 65-year-old man, who had undergone living donor LT for HCC 2 years before. His main symptom was progressive gait disturbance because of the spinal cord compression by the tumor at T7. Radiology and pathology examinations revealed a solitary metastasis at T7 with neither recurrence in the liver nor metastasis in the other organs. We performed TES using a pedicle screw system and a mesh cage filled with frozen autografts. RESULTS After surgery, the patient showed clear improvement in neurological symptoms. At 3 months after surgery, a T4 metastasis was detected with magnetic resonance imaging, and the patient was treated with heavy ion radiotherapy. He could walk without a cane and there was no evidence of recurrence at 1.5 years after surgery. CONCLUSIONS Solitary spinal metastasis of HCC may become an indication for TES if liver function improves after LT. LEVEL OF EVIDENCE 5.
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Yim HJ, Suh SJ, Um SH. Current management of hepatocellular carcinoma: an Eastern perspective. World J Gastroenterol 2015; 21:3826-42. [PMID: 25852267 PMCID: PMC4385529 DOI: 10.3748/wjg.v21.i13.3826] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 12/11/2014] [Accepted: 02/12/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the leading causes of cancer death, especially in Eastern areas. With advancements in diagnosis and treatment modalities for HCC, the survival and prognosis of HCC patients are improving. However, treatment patterns are not uniform between areas despite efforts to promote a common protocol. Although many hepatologists in Asian countries may adopt the principles of the Barcelona Clinic Liver Cancer staging system, they are also independently making an effort to expand the indications of each treatment and to combine therapies for better outcomes. Several expanded criteria for liver transplantation in HCC have been developed in Asian countries. Living donor liver transplantation is much more commonly performed in these countries than deceased donor liver transplantation, and it may be preceded by other treatments such as the down-staging of tumors. Local ablation therapies are often combined with transarterial chemoembolization (TACE) and the outcome is comparable to that of surgical resection. The indications of TACE are expanding, and there are new types of transarterial therapies. Although data on drug-eluting beads, TACE, and radioembolization in Asian countries are still relatively sparse compared with Western countries, these methods are gradually gaining popularity because of better tolerability and the possibility of improved response rates. Hepatic arterial infusion chemotherapy and radiotherapy are not included in Western guidelines, but are currently being used actively in several Asian countries. For more advanced HCCs, appropriate combinations of TACE, radiotherapy, and sorafenib can be considered, and emerging data indicate improved outcomes of combination therapies compared with single therapies. To include these paradigm shifts into newer treatment guidelines, more studies may be needed, but they are certainly in progress.
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Yang YC, Tsai ST. Surgical salvage for sudden quadriplegia due to recurrent hepatocellular carcinoma with spinal metastasis. Tzu Chi Med J 2014. [DOI: 10.1016/j.tcmj.2013.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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18
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Kim CH, Chung CK, Sohn S, Lee S, Park SB. Less invasive palliative surgery for spinal metastases. J Surg Oncol 2013; 108:499-503. [DOI: 10.1002/jso.23418] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 07/31/2013] [Indexed: 11/06/2022]
Affiliation(s)
- Chi Heon Kim
- Department of Neurosurgery; Seoul National University Hospital and College of Medicine; Seoul South Korea
- Neuroscience Research Institute; Seoul National University Medical Research Center; Seoul South Korea
- Clinical Research Institute; Seoul National University Hospital; Seoul South Korea
| | - Chun Kee Chung
- Department of Neurosurgery; Seoul National University Hospital and College of Medicine; Seoul South Korea
- Neuroscience Research Institute; Seoul National University Medical Research Center; Seoul South Korea
- Clinical Research Institute; Seoul National University Hospital; Seoul South Korea
| | - Seil Sohn
- Department of Neurosurgery; Seoul National University Hospital and College of Medicine; Seoul South Korea
- Neuroscience Research Institute; Seoul National University Medical Research Center; Seoul South Korea
- Clinical Research Institute; Seoul National University Hospital; Seoul South Korea
| | - Sungjoon Lee
- Department of Neurosurgery; Seoul National University Hospital and College of Medicine; Seoul South Korea
- Neuroscience Research Institute; Seoul National University Medical Research Center; Seoul South Korea
- Clinical Research Institute; Seoul National University Hospital; Seoul South Korea
| | - Sung Bae Park
- Department of Neurosurgery; Seoul National University Hospital and College of Medicine; Seoul South Korea
- Department of Neurosurgery; Seoul National University Boramae Hospital; Seoul South Korea
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Surgery and prognostic factors of patients with epidural spinal cord compression caused by hepatocellular carcinoma metastases: retrospective study of 36 patients in a single center. Spine (Phila Pa 1976) 2013; 38:E1090-5. [PMID: 23632333 DOI: 10.1097/brs.0b013e3182983bf8] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective study of 36 patients with metastatic hepatocellular carcinoma (HCC) of the mobile spine was performed by survival analysis. OBJECTIVE To discuss the factors that may affect outcomes of patients with HCC spinal metastases. SUMMARY OF BACKGROUND DATA HCC is a rare tumor in Western countries. However, HCC is common in Far East (Taiwan, Korea, mainland China), where the hepatitis B virus is epidemic. As the mean survival time of patients with HCC has largely increased in recent years, it is now more common to encounter a patient with epidural spinal cord compression caused by HCC spinal metastases in clinic. METHODS The univariate and multivariate analyses of various clinical factors were performed to identify independent variables that could predict prognosis. The survival rate was estimated by the Kaplan-Meier method, and differences were analyzed by the log-rank test. Factors with P values of 0.1 or less were subjected to multivariate analysis for survival rate by multivariate Cox proportional hazards analysis. RESULTS A total of 36 patients with metastatic HCC of the mobile spine were included in the study. Age (≤45 yr/>45 yr), duration of preoperative symptoms (<6 mo/≥6 mo), preoperative Frankel score (A-C/D-E), Tomita score (5-7/8-10), and bisphosphonate treatment were suggested as the potential prognostic factors through univariate analysis. However, as they were submitted to the multivariate Cox regression model, only Tomita score was found as an independent prognostic factor. CONCLUSION Tomita score no more than 7 is a favorable prognostic factor for HCC metastases in the mobile spine. LEVEL OF EVIDENCE 4.
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Pre- and postoperative lower extremity motor power and ambulatory status of patients with spinal cord compression due to a metastatic spinal tumor. Spine (Phila Pa 1976) 2013; 38:E798-802. [PMID: 23532120 DOI: 10.1097/brs.0b013e3182927559] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of medical records. OBJECTIVE To describe pre- and postoperative ambulatory status and lower limb motor power, and compare characteristics of patients with metastatic spinal cord compression (MSCC) who were ambulatory at 48 hours postoperatively with those of patients with MSCC who were nonambulatory. SUMMARY OF BACKGROUND DATA Preoperative motor power of the lower extremities is a predictor of postoperative ambulatory status in patients with MSCC. METHODS We retrospectively evaluated the medical records of 102 consecutive patients with MSCC who presented for decompressive surgery with lower extremity weakness between January 1997 and December 2010. A single surgeon classified the preoperative and 48-hour postoperative motor power of the lower extremities on a 6-point scale. Ambulation status was determined 48 hours after surgery and patients were classified as ambulatory (including normal ambulation, ambulation with aid, and ambulation without aid) or nonambulatory. Demographic and clinical characteristics were compared between patients who were ambulatory and those who were nonambulatory at 48 hours postoperatively. RESULTS Motor power was improved 1.05 ± 0.73 grades after operation. Two-thirds of patients who were preoperatively classified as nonambulatory were ambulatory at 48 hours postoperatively. The only significantly different affecting factor between the postoperative ambulatory group and the nonambulatory group was preoperative lower extremity power and preoperative capability of ambulation. In addition, grade III of lower extremity motor power was significant criteria for postoperative ambulation. CONCLUSION We recommend aggressive decompressive surgery in patients with MSCC if preoperative lower extremity motor power is at least grade III, although all groups of preoperative lower extremity motor power had 1 or more patients who returned to ambulation. LEVEL OF EVIDENCE 3.
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Kim CH, Chung CK, Jahng TA, Kim HJ. Resumption of ambulatory status after surgery for nonambulatory patients with epidural spinal metastasis. Spine J 2011; 11:1015-23. [PMID: 22000724 DOI: 10.1016/j.spinee.2011.09.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Revised: 05/19/2011] [Accepted: 09/07/2011] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Improving the surgical outcome of nonambulatory patients with metastatic epidural spinal compression has been of great interest lately. Although there have been many reports regarding the surgical outcome of spinal metastasis, the surgical outcome in terms of the probability of operative success for nonambulatory patients has not been thoroughly described. If the probability of ambulatory recovery is known, the optimal surgical indications can be determined and implemented. PURPOSE To predict the surgical outcome and probability of ambulatory resumption for nonambulatory patients with spinal metastasis. STUDY DESIGN Retrospective analysis. PATIENT SAMPLE The surgical outcomes of patients who could not ambulate independently because of spinal metastasis from 1987 to 2010 were analyzed. OUTCOME MEASURES The primary end point was postoperative ambulatory status. The secondary end point was survival time. METHODS Fifty-seven patients who could not ambulate independently at the time of surgery were included in the study. We defined "independent ambulation" as a better functional status than Nurick Grade 3, which is defined as "difficulty in walking which was not so severe as to require someone's help to walk." Preoperatively, functional status was Nurick Grade 4 in 21 patients and Grade 5 in 36 patients. Weakness developed 10.5 ± 11.9 days (median, 7.0; range, 1-80) before the operation and steadily worsened. Patients were unable to walk starting from 3.6 ± 4.9 days (median, 1.8; range, 0.5-23) before the operation. The spinal metastases were circumferentially decompressed. RESULTS Postoperatively, 39 patients (68%) could walk. Complications occurred in 26% (15/57) of the patients, and the major complication rate was 12% (7/57). The mortality rate was 5% (3/57). The patient survival time was 287 ± 51 days (median, 128) after the operation. Postoperative ambulatory status (yes vs. no, p < .01) and occurrence of major complication (yes vs. no, p < .01) affected survival time. Overall, patients could walk for 193±41 days (median, 114) postoperatively. Motor grade (grade ≥ 4/5 vs. <4/5, p < .01) and the occurrence of a major complication (yes vs. no, p < .01) were significant factors for resumption of ambulation. The rate of ambulation resumption was 95% (20/21) in patients with a motor grade of 4 of 5, whereas it was 53% (19/36) in patients with a motor grade less than 4 of 5 (p < .01). CONCLUSIONS The survival time of nonambulatory patients was dependent on ambulation recovery. About 95% of the nonambulatory patients could walk after surgery, when the operation was done in a timely manner with good remaining motor function. However, given the short life expectancy and the considerable surgical complication rate, surgery should only be prudently recommended to patients with optimal indications.
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Affiliation(s)
- Chi Heon Kim
- Department of Neurosurgery, Seoul National University Hospital, 28 Yeongeon-dong, Jongno-gu, Seoul 110-744, South Korea
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