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Boonchai K, Santipas B, Wilartratsami S, Ruangchainikom M, Korwutthikulrangsri E, Akkarawanit P, Luksanapruksa P. The Magnetic Resonance Imaging of the Psoas Muscle Area as the Prognostic Factor for Survival and Adverse Events in Spinal Metastasis Surgery. Global Spine J 2024:21925682231173366. [PMID: 39069656 DOI: 10.1177/21925682231173366] [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: 07/30/2024] Open
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE This study aimed to evaluate the ability of the mortality and adverse events prediction following metastatic spinal surgery of MRI-based cross-sectional psoas muscle area (PMA). METHODS A retrospective chart review, 120 patients who had undergone metastatic spinal surgery were included. The cross-sectional area identified the PMA under MR-imaging at the L3 or L4 pedicle level, which was classified into 3 tertiles. We used univariate and multivariate cox proportional hazard regression to assess whether PMA was associated with 30-day, 90-day, 1-year, and overall mortality. RESULTS The small psoas tertile group populations had a higher mortality rate than the large psoas tertile group. PMA in T1 and T2 had a probability of a higher 90-d mortality rate than PMA in T3 (T1 VS T3: P = .29 and T2 VS T3: P = .12). The median survival time was 7 months, 9 months, and 10 months in PMA T1, T2, and T3, respectively. PMA in tertile 2 had a significantly higher mortality rate of 38% compared to PMA in tertile 3 (HR 1.38, 95% CI .83-2.32, P = .02). Considering PMA as a continuous variable, every 1 mm2 increment of PMA resulted in the increase survivorship of 1% (HR .99 with 95% CI .99-1). CONCLUSION The MRI-based cross-sectional PMA tends to predict the 90-d mortality rate and overall mortality rate in spinal metastasis patients who underwent spinal surgery. The PMA should be considered one of the prognostic factors in the treatment of metastatic spinal patients.
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Affiliation(s)
- Kitidate Boonchai
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Borriwat Santipas
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sirichai Wilartratsami
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Monchai Ruangchainikom
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ekkapoj Korwutthikulrangsri
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pawin Akkarawanit
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Panya Luksanapruksa
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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2
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González-Kusjanovic N, Delgado Ochoa B, Vidal C, Campos M. Post-operative complications affect survival in surgically treated metastatic spinal cord compression. INTERNATIONAL ORTHOPAEDICS 2024; 48:1341-1350. [PMID: 38472466 DOI: 10.1007/s00264-024-06120-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 01/13/2024] [Indexed: 03/14/2024]
Abstract
PURPOSE The prevalence of metastatic epidural spinal cord compression (MESCC) is increasing globally due to advancements in cancer diagnosis and treatment. Whilst surgery can benefit specific patients, the complication rate can reach up to 34%, with limited reporting on their impact in the literature. This study aims to analyse the influence of major complications on the survival of surgically treated MESCC patients. METHODS Consecutive MESCC patients undergoing surgery and meeting inclusion criteria were selected. Survival duration from decompressive surgery to death was recorded. Perioperative factors influencing survival were documented and analysed. Kaplan-Meier survival analysis at one year compared these factors. Univariate and multivariate Cox proportional hazard regression analyses were performed. Additionally, univariate analysis compared complicated and uncomplicated groups. RESULTS Seventy-five patients were analysed. Median survival for this cohort was 229 days (95% CI 174-365). Surgical complications, low patient performance, and rapid primary tumour growth were significant perioperative variables for survival in multivariate analyses (p < 0.001, p = 0.003, and p = 0.02, respectively) with a hazard ratio of 3.2, 3.6, and 2.1, respectively. Univariate analysis showed no variables associated with complication occurrence. CONCLUSION In this cohort, major surgical complications, patient performance, and primary tumour growth rate were found to be independent factors affecting one year survival. Thus, prioritizing complication prevention and appropriate patient selection is crucial for optimizing survival in this population.
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Affiliation(s)
- Nicolás González-Kusjanovic
- Orthopaedic Surgery Department, School of Medicine, Pontificia Universidad Católica de Chile, Diagonal Paraguay, 362, Santiago, Chile
| | - Byron Delgado Ochoa
- Orthopaedic Surgery Department, School of Medicine, Pontificia Universidad Católica de Chile, Diagonal Paraguay, 362, Santiago, Chile
| | - Catalina Vidal
- Orthopaedic Surgery Department, School of Medicine, Pontificia Universidad Católica de Chile, Diagonal Paraguay, 362, Santiago, Chile
| | - Mauricio Campos
- Orthopaedic Surgery Department, School of Medicine, Pontificia Universidad Católica de Chile, Diagonal Paraguay, 362, Santiago, Chile.
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Yang M, Ma X, Wang P, Yang J, Zhong N, Liu Y, Shen J, Wan W, Jiao J, Xu W, Xiao J. Prediction of Survival Prognosis for Spinal Metastasis From Cancer of Unknown Primary: Derivation and Validation of a Nomogram Model. Global Spine J 2024; 14:283-294. [PMID: 35615968 PMCID: PMC10676151 DOI: 10.1177/21925682221103833] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective and prospective cohort study. OBJECTIVES Survival estimation is necessary in the decision-making process for treatment in patients with spinal metastasis from cancer of unknown primary (SMCUP). We aimed to develop a novel survival prediction system and compare its accuracy with that of existing survival models. METHODS A retrospective derivation cohort of 268 patients and a prospective validation cohort of 105 patients with SMCUP were performed. Univariate and multivariable survival analysis were used to generate independently prognostic variables. A nomogram model for survival prediction was established by integrating these independent predictors based on the size of the significant variables' β regression coefficient. Then, the model was subjected to bootstrap validation with calibration curves and concordance index (C-index). Finally, predictive accuracy was compared with Tomita, revised Tokuhashi and SORG score by the receiver-operating characteristic (ROC) curve. RESULTS The survival prediction model included six independent prognostic factors, including pathology (P < .001), visceral metastases (P < .001), Frankel score (P < .001), weight loss (P = .005), hemoglobin (P = .001) and serum tumor markers (P < .001). Calibration curve of the model showed good agreement between predicted and actual mortality risk in 6-, 12-, and 24-month estimation in derivation and validation cohorts. The C-index was .775 in the derivation cohort and .771 in the validation cohort. ROC curve analysis showed that the current model had the best accuracy for SMCUP survival estimation amongst 4 models. CONCLUSIONS The novel nomogram system can be applied in survival prediction for SMCUP patients, and furtherly be used to give individualized therapeutic suggestions based on patients' prognosis.
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Affiliation(s)
- Minglei Yang
- Department of Orthopedic Oncology, The Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Xiaoyu Ma
- Department of Orthopedic Oncology, The Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Pengru Wang
- Department of Orthopedic Oncology, The Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Jiaxiang Yang
- Department of Orthopedic Oncology, The Second Affiliated Hospital of Naval Medical University, Shanghai, China
- Department of Orthopedics, Traditional Chinese Hospital of LuAn, Anhui, China
| | - Nanzhe Zhong
- Department of Orthopedic Oncology, The Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Yujie Liu
- Department of Orthopedic Oncology, The Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Jun Shen
- Department of Orthopedic Oncology, The Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Wei Wan
- Department of Orthopedic Oncology, The Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Jian Jiao
- Department of Orthopedic Oncology, The Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Wei Xu
- Department of Orthopedic Oncology, The Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Jianru Xiao
- Department of Orthopedic Oncology, The Second Affiliated Hospital of Naval Medical University, Shanghai, China
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Tan JHJ, Hallinan JTPD, Ang SW, Tan TH, Tan HIJ, Tan LTI, Sin QS, Lee R, Hey HWD, Chan YH, Liu KPG, Kumar N. Outcomes and Complications of Surgery for Symptomatic Spinal Metastases; a Comparison Between Patients Aged ≥ 70 and <70. Global Spine J 2023:21925682231209624. [PMID: 37880960 DOI: 10.1177/21925682231209624] [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: 10/27/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Physicians may be deterred from operating on elderly patients due to fears of poorer outcomes and complications. We aimed to compare the outcomes of surgical treatment of spinal metastases patients aged ≥70-yrs and <70-yrs. MATERIALS AND METHODS This is a retrospective study of patients surgically treated for metastatic epidural spinal cord compression and spinal instability between January-2005 to December-2021. Follow-up was till death or minimum 1-year post-surgery. Outcomes included post-operative neurological status, ambulatory status, medical and surgical complications. Two Sample t-test/Mann Whitney U test were used for numerical variables and Pearson Chi-Squared or Fishers Exact test for categorical variables. Survival was presented with a Kaplan-Meier curve. P < .05 was significant. RESULTS We identified 412 patients of which 29 (7.1%) patients were excluded due to loss to follow-up and previous surgical treatment. 79 (20.6%) were ≥70-yrs. Age ≥70-yrs patients had poorer ECOG scores (P = .0017) and Charlson Comorbidity Index (P < .001). No significant difference in modified Tokuhashi score (P = .393) was observed with significantly more ≥ prostate (P < .001) and liver (P = .029) cancer in ≥70-yrs. Improved or maintained normal neurological function (P = .934), independent ambulatory status (P = .171), and survival at 6 months (P = .119) and 12 months (P = .659) was not significantly different between both groups. Medical (P = .528) or surgical (P = .466) complication rates and readmission rates (P = .800) were similar. CONCLUSION ≥70-yrs patients have comparable outcomes to <70-yr old patients with no significant increase in complication rates. Age should not be a determining factor in deciding surgical management of spinal metastases.
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Affiliation(s)
| | | | - Shi Wei Ang
- Yong Loo Lin School of Medicine, NUHS, Singapore
| | - Tuan Hao Tan
- Yong Loo Lin School of Medicine, NUHS, Singapore
| | | | | | | | - Renick Lee
- Department of Orthopaedic Surgery, National University Health System, Singapore
| | | | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Block MD11, Clinical Research Centre, 10 Medical Drive, Singapore
| | - Ka Po Gabriel Liu
- Department of Orthopaedic Surgery, National University Health System, Singapore
| | - Naresh Kumar
- Department of Orthopaedic Surgery, National University Health System, Singapore
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5
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Huang AP, Yang CY, Xiao F, Yang SH, Chen CM, Lai DM, Tsuang FY. Spinal metastases from non-small cell lung cancer - Is surgical extent enough by following suggestions of the Tomita and Tokuhashi scores? Asian J Surg 2023:S1015-9584(23)01332-5. [PMID: 37684123 DOI: 10.1016/j.asjsur.2023.08.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/31/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND/OBJECTIVE The Tomita, revised Tokuhashi and Tokuhashi lung scores are commonly used tools to predict the survival of patients with spinal metastases and to guide decisions regarding surgical treatment. These prognostic scores, however, tend to underestimate the prognosis of patients with lung cancer. We examined surgical outcome and hopefully provide a more accurate reference for management. METHODS The consistency between predicted and actual survival was examined using the Tomita and Tokuhashi scores. Various factors that may influence survival were analyzed. Primary outcomes were overall survival (OS) and progression-free survival (PFS), defined as the ambulatory time after the initial surgery. Secondary outcomes included reoperation events, blood loss, and hospitalization days. RESULTS One hundred seventy-two patients were enrolled. Correct survival predictions were made for 28%, 42%, and 56% with the Tomita, revised Tokuhashi, and Tokuhashi lung scores, respectively. The Tokuhashi lung scores underestimated OS by 35%-40%. Body mass index ≥20, systemic treatment-naïve, good general condition, the use of denosumab, and adenocarcinoma were found to positively affect OS and PFS. There was no significant difference between palliative decompression and excisional surgery regarding OS and PFS. CONCLUSION Patients with spinal metastases from lung cancer had better prognosis than that predicted by the Tomita and Tokuhashi scores. Spine surgeons should acknowledge this discrepancy and treat these patients with at least the aggressiveness suggested. Patients with adenocarcinoma, amenable to target therapy, denosumab, good general condition, systemic treatment-naïve are better candidates for surgery. Those with cachexic status and unresectable visceral metastases are worse candidates.
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Affiliation(s)
- An-Ping Huang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taiwan; Spine Tumor Center, National Taiwan University Hospital, Taiwan
| | - Ching-Yao Yang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taiwan
| | - Furen Xiao
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taiwan; Spine Tumor Center, National Taiwan University Hospital, Taiwan
| | - Shih-Hung Yang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taiwan; Spine Tumor Center, National Taiwan University Hospital, Taiwan
| | - Chang-Mu Chen
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taiwan; Spine Tumor Center, National Taiwan University Hospital, Taiwan
| | - Dar-Ming Lai
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taiwan; Spine Tumor Center, National Taiwan University Hospital, Taiwan
| | - Fon-Yih Tsuang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taiwan; Spine Tumor Center, National Taiwan University Hospital, Taiwan.
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6
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McCabe FJ, McCabe JP, Murray O. Reply to letter to the editor regarding "A novel scoring system incorporating sarcopenia to predict postoperative survival in spinal metastasis". Spine J 2023; 23:1401-1402. [PMID: 37611973 DOI: 10.1016/j.spinee.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 06/06/2023] [Indexed: 08/25/2023]
Affiliation(s)
- Fergus J McCabe
- Spine Service, Department of Trauma and Orthopedic Surgery, Galway University Hospitals, Galway, Ireland; University of Galway, Galway, Ireland.
| | - John P McCabe
- Spine Service, Department of Trauma and Orthopedic Surgery, Galway University Hospitals, Galway, Ireland; University of Galway, Galway, Ireland
| | - Odhrán Murray
- Spine Service, Department of Trauma and Orthopedic Surgery, Galway University Hospitals, Galway, Ireland
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7
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Hamed M, Brandecker S, Rana S, Potthoff AL, Eichhorn L, Bode C, Schmeel FC, Radbruch A, Schäfer N, Herrlinger U, Köksal M, Giordano FA, Vatter H, Schneider M, Banat M. Postoperative prolonged mechanical ventilation correlates to poor survival in patients with surgically treated spinal metastasis. Front Oncol 2022; 12:940790. [PMID: 36387073 PMCID: PMC9647167 DOI: 10.3389/fonc.2022.940790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 10/13/2022] [Indexed: 12/02/2022] Open
Abstract
Objective Patients with spinal metastasis (SM) are at advanced stages of systemic cancer disease. Surgical therapy for SM is a common treatment modality enabling histopathological diagnosis and the prevention of severe neurological deficits. However, surgery for SM in this vulnerable patient cohort may require prolonged postoperative intensive care treatment, which could adversely affect the anticipated benefit of the surgery. We therefore assessed postoperative prolonged mechanical ventilation (PMV) as an indicator for intensive care treatment with regard to potential correlations with early postoperative mortality and overall survival (OS). Methods Between 2015 and 2019, 198 patients were surgically treated for SM at the author´s neurosurgical department. PMV was defined as postoperative mechanical ventilation of more than 24 hours. A multivariate analysis was performed to identify pre- and perioperative collectable predictors for 30 days mortality. Results Twenty out of 198 patients (10%) with SM suffered from postoperative PMV. Patients with PMV exhibited a median OS rate of 1 month compared to 12 months for patients without PMV (p < 0.0001). The 30 days mortality was 70% and after one year 100%. The multivariate analysis identified “PMV > 24 hrs” (p < 0.001, OR 0.3, 95% CI 0.02-0.4) as the only significant and independent predictor for 30 days mortality (Nagelkerke’s R2 0.38). Conclusions Our data indicate postoperative PMV to significantly correlate to high early postoperative mortality rates as well as to poor OS in patients with surgically treated SM. These findings might encourage the initiation of further multicenter studies to comprehensively investigate PMV as a so far underestimated negative prognostic factor in the course of surgical treatment for SM.
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Affiliation(s)
- Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Simon Brandecker
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Shaleen Rana
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | | | - Lars Eichhorn
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Christian Bode
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | | | | | - Niklas Schäfer
- Division of Clinical Neurooncology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Ulrich Herrlinger
- Division of Clinical Neurooncology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Mümtaz Köksal
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | | | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | | | - Mohammed Banat
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
- *Correspondence: Mohammed Banat,
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Prognostic factors for survival and ambulatory status at 8 weeks with metastatic spinal cord compression in the SCORAD randomised trial. Radiother Oncol 2022; 173:77-83. [PMID: 35618101 DOI: 10.1016/j.radonc.2022.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 05/17/2022] [Accepted: 05/18/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Metastatic spinal cord compression (MSCC) carries a poor prognosis and management is based on the likelihood of maintaining mobility and predicted survival. PATIENTS AND METHOD SCORAD is a randomised trial of 686 patients comparing a single dose of 8 Gy radiotherapy with 20 Gy in 5 fractions. Data was split into a training set (412, 60%) and a validation set (274, 40%). A multivariable Cox regression for overall survival (OS) and a logistic regression for ambulatory status at 8 weeks were performed in the training set using baseline factors and a backward selection regression to identify a parsimonious model with p ≤ 0.10. Receiver Operating Characteristic (ROC) analysis evaluated model prognostic performance in the validation set. Validation of the final survival model was performed in a separate registry dataset (n = 348). RESULTS The survival Cox model identified male gender, lung, gastrointestinal, and other types of cancer, compression at C1-T12, presence of non-skeletal metastases and poor ambulatory status all significantly associated with worse OS (all p < 0.05). The ROC AUC for the selected model was 75% (95%CI: 69-81) in the SCORAD validation set and 68% (95%CI: 62-74) in the external validation registry data. The logistic model for ambulatory outcome identified primary tumour breast or prostate, ambulatory status grade 1 or 2, bladder function normal and prior chemotherapy all significantly associated with increased odds of ambulation at 8 weeks (all p < 0.05). The ROC AUC for the selected model was 72.3% (95% CI 62.6-82.0) in the validation set. CONCLUSIONS Primary breast or prostate cancer, and good ambulatory status at presentation, are favourable prognostic factors for both survival and ambulation after treatment.
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9
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De Meue E, Smeijers S, Langmans C, Clement PM, Depreitere B. Identifying new predictive factors for survival after surgery for spinal metastases: an exploratory in-depth retrospective analysis. Acta Clin Belg 2022; 77:606-615. [PMID: 33956576 DOI: 10.1080/17843286.2021.1925028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES In selected patients with symptomatic spinal metastasis from solid tumors, surgery improves quality of life. Since selection is key, inaccurate survival prognostication may result in poor decisions and outcomes. However, most prognostic scores suffer from suboptimal external validation and subsequent mediocre performance. This warrants the ongoing search for factors that better capture the oncological status. This exploratory study aims to identify new preoperative variables that predict survival. METHODS A retrospective analysis was conducted on 62 patients from a tertiary care referral center who underwent debulking and/or reconstruction surgery for spinal metastases between 2006 and 2018, and in whom detailed clinical, oncological, surgical and biochemical variables were collected. Univariate and multivariate analyses were performed for overall survival. RESULTS Median survival was 13.2 months. Multivariate analysis for overall survival identified that a higher number of organs with metastases, a shorter time to progression on the last line of systemic therapy before surgery (TTPbs), low serum albumin, high alkaline phosphatase, high C-reactive peptide (CRP), presence of brain metastasis and the index spinal level located in the cervical region were independently associated with shorter survival. CONCLUSION We confirmed previously known predictors and identified CRP and TTPbs as new variables that were strongly associated with survival. The latter variable may replace primary tumor type, as improved cancer treatments make the primary tumor type less relevant as a predictor. This study is exploratory and its findings need to be validated, preferably in large prospective multicenter studies that are aiming at improving existing models.
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Affiliation(s)
- Elisabeth De Meue
- Department of General Medical Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Steven Smeijers
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Ciska Langmans
- Department of Medical Oncology, OLV Hospital, Aalst, Belgium
| | - Paul M. Clement
- Department of General Medical Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Bart Depreitere
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
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10
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The Palliative Care in the Metastatic Spinal Tumors. A Systematic Review on the Radiotherapy and Surgical Perspective. Life (Basel) 2022; 12:life12040571. [PMID: 35455062 PMCID: PMC9032747 DOI: 10.3390/life12040571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/18/2022] [Accepted: 04/08/2022] [Indexed: 12/17/2022] Open
Abstract
Spine represents the most common site for metastatic disease involvement. Due to the close relationship between the spinal cord and critical structures, therapeutical management of metastatic spinal cord disease remains challenging. Spinal localization can lead to neurological sequelae, which can significantly affect the quality of life in patients with a limited life expectancy. The authors conducted a systematic literature review according to PRISMA guidelines in order to determine the impact of the most updated palliative care on spinal metastases. The initial literature search retrieved 2526 articles, manually screened based on detailed exclusion criteria. Finally, 65 studies met the inclusion criteria and were finally included in the systematic review. In the wide scenario of palliative care, nowadays, recent medical or surgical treatments represent valuable options for ameliorating pain and improving patients QoL in such this condition.
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11
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Serratrice N, Faddoul J, Tarabay B, Attieh C, Chalah MA, Ayache SS, Abi Lahoud GN. Ten Years After SINS: Role of Surgery and Radiotherapy in the Management of Patients With Vertebral Metastases. Front Oncol 2022; 12:802595. [PMID: 35155240 PMCID: PMC8829066 DOI: 10.3389/fonc.2022.802595] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 01/05/2022] [Indexed: 12/02/2022] Open
Abstract
The objective of the different types of treatments for a spinal metastasis is to provide the best oncological and functional result with the least aggressive side effects. Initially created in 2010 to help clinicians in the management of vertebral metastases, the Spine Instability Neoplastic Score (SINS) has quickly found its place in the decision making and the treatment of patients with metastatic spinal disease. Here we conduct a review of the literature describing the different changes that occurred with the SINS score in the last ten years. After a brief presentation of the spinal metastases’ distribution, with or without spinal cord compression, we present the utility of SINS in the radiological diagnosis and extension of the disease, in addition to its limits, especially for scores ranging between 7 and 12. We take this opportunity to expose the latest advances in surgery and radiotherapy concerning spinal metastases, as well as in palliative care and pain control. We also discuss the reliability of SINS amongst radiologists, radiation oncologists, spine surgeons and spine surgery trainees. Finally, we will present the new SINS-derived predictive scores, biomarkers and artificial intelligence algorithms that allow a multidisciplinary approach for the management of spinal metastases.
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Affiliation(s)
- Nicolas Serratrice
- Institut de la Colonne Vertébrale et des NeuroSciences (ICVNS) - CMC Bizet, Paris, France
| | - Joe Faddoul
- Institut de la Colonne Vertébrale et des NeuroSciences (ICVNS) - CMC Bizet, Paris, France.,Department of Neurosurgery, Centre Hospitalier de la Côte Basque, Bayonne, France
| | - Bilal Tarabay
- Institut de la Colonne Vertébrale et des NeuroSciences (ICVNS) - CMC Bizet, Paris, France
| | - Christian Attieh
- Institut de la Colonne Vertébrale et des NeuroSciences (ICVNS) - CMC Bizet, Paris, France
| | - Moussa A Chalah
- Institut de la Colonne Vertébrale et des NeuroSciences (ICVNS) - CMC Bizet, Paris, France.,Univ Paris Est Créteil, Excitabilité Nerveuse et Thérapeutique (ENT), EA 4391, Créteil, France
| | - Samar S Ayache
- Institut de la Colonne Vertébrale et des NeuroSciences (ICVNS) - CMC Bizet, Paris, France.,Univ Paris Est Créteil, Excitabilité Nerveuse et Thérapeutique (ENT), EA 4391, Créteil, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Henri Mondor University Hospital, Department of Clinical Neurophysiology, DMU FIxIT, Créteil, France
| | - Georges N Abi Lahoud
- Institut de la Colonne Vertébrale et des NeuroSciences (ICVNS) - CMC Bizet, Paris, France
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12
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Kramer A, Coßmann T, Jägersberg M, Preuß A, Meyer B, Ringel F. The Oswestry Spinal Risk Index (OSRI) in assessing prognosis of patients with spinal metastases. BRAIN AND SPINE 2022; 2:100875. [PMID: 36248120 PMCID: PMC9560541 DOI: 10.1016/j.bas.2022.100875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 01/17/2022] [Accepted: 02/23/2022] [Indexed: 11/06/2022]
Abstract
Introduction The Oswestry Spinal Risk Index (OSRI) was designed to predict life expectancy of patients presenting with spinal metastases. It integrates the most predictive items of existing scores and is calculated using not more than two items: General condition and primary tumor. Research question The purpose of this study was to externally validate the OSRI in a large cohort and to compare it with the established scores. Material and methods We retrospectively identified 211 consecutive surgical patients with symptomatic spinal metastases. We collected clinical and radiographic data, such as Karnofsky Performance Score (KPS), Frankel Status, primary tumor pathology and metastatic spread to calculate the Tokuhashi score, Tomita score, modified Bauer score and the OSRI. Logistic regression models, Kaplan-Meyer-curves, discriminant power and variance analyses were applied using Harrell’s C-index and Cox and Snell’s Pseudo R². Results Predicted and actual survival of our cohort’s patients correlated significantly in each investigated scoring systems (p < 0.001). In test quality measurements Tokuhashi score performed best (C = 0.7204; R² = 0.3619), followed by OSRI (C = 0.7023; R² = 0.2612), Tomita (C = 0.6748; R² = 0.2818) and modified Bauer score (C = 0.6653; R² = 0.2486). Accuracy of predicted life expectancy was highest in modified Bauer score and OSRI. Discussion and conclusion Compared to the original scores, the OSRI provided equal or even superior results in assessing our study population’s life expectancy. Its particular advantage lies in the simplicity of its application, which well meets the demands of surgical decision-making in daily practice. Prognosis prediction in patients with spinal metastases. Calculation of Oswestry Spinal Risk Index. Comparison of prognosis scores in spinal metastases.
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Smeijers S, Depreitere B. Prognostic scores for survival as decisional support for surgery in spinal metastases: a performance assessment systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:2800-2824. [PMID: 34398337 DOI: 10.1007/s00586-021-06954-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 07/02/2021] [Accepted: 08/01/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE To review the evidence on the relative prognostic performance of the available prognostic scores for survival in spinal metastatic surgery in order to provide a recommendation for use in clinical practice. METHODS A systematic review of comparative external validation studies assessing the performance of prognostic scores for survival in independent cohorts was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Eligible studies were identified through Medline and Embase until May 2021. Studies were included when they compared at least four survival scoring systems in surgical or mixed cohorts across all primary tumor types. Predictive performance was assessed based on discrimination and calibration for 3-month, 1-year and overall survival, and generalizability was assessed based on the characteristics of the development cohort and external validation cohorts. Risk of bias and concern regarding applicability were assessed based on the 'Prediction model study Risk Of Bias Assessment Tool' (PROBAST). RESULTS Twelve studies fulfilled the inclusion criteria and covered 17 scoring systems across 5.130 patients. Several scores suffer from suboptimal development and validation. The SORG Nomogram, developed in a large surgical cohort, showed good discrimination on 3-month and 1-year survival, good calibration and was superior in direct comparison with low risk of bias and low concern regarding applicability. Machine learning algorithms are promising as they perform equally well in direct comparison. Tokuhashi, Tomita and other traditional risk scores showed suboptimal performance. CONCLUSION The SORG Nomogram and machine learning algorithms outline superior performance in survival prediction for surgery in spinal metastases. Further improvement by comparative validation in large multicenter, prospective cohorts can still be obtained. Given the heterogeneity of spinal metastases, superior methodology of development and validation is key in improving future machine learning systems.
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Affiliation(s)
- S Smeijers
- Department of Neurosurgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - B Depreitere
- Department of Neurosurgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
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Gouveia AG, Chan DCW, Hoskin PJ, Marta GN, Trippa F, Maranzano E, Chow E, Silva MF. Advances in radiotherapy in bone metastases in the context of new target therapies and ablative alternatives: A critical review. Radiother Oncol 2021; 163:55-67. [PMID: 34333087 DOI: 10.1016/j.radonc.2021.07.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 07/05/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
In patients with bone metastases (BM), radiotherapy (RT) is used to alleviate symptoms, reduce the risk of fracture, and improve quality of life (QoL). However, with the emergence of concepts like oligometastases, minimal invasive surgery, ablative therapies such as stereotactic ablative RT (SABR), radiosurgery (SRS), thermal ablation, and new systemic anticancer therapies, there have been a paradigm shift in the multidisciplinary approach to BM with the aim of preserving mobility and function survival. Despite guidelines on using single-dose RT in uncomplicated BM, its use remains relatively low. In uncomplicated BM, single-fraction RT produces similar overall and complete response rates to RT with multiple fractions, although it is associated with a higher retreatment rate of 20% versus 8%. Complicated BM can be characterised as the presence of impending or existing pathologic fracture, a major soft tissue component, existing spinal cord or cauda equina compression and neuropathic pain. The rate of complicated BM is around 35%. Unfortunately, there is a lack of prospective trials on RT in complicated BM and the best dose/fractionation regimen is not yet established. There are contradictory outcomes in studies reporting BM pain control rates and time to pain reduction when comparing SABR with Conventional RT. While some studies showed that SABR produces a faster reduction in pain and higher pain control rates than conventional RT, other studies did not show differences. Moreover, the local control rate for BM treated with SABR is higher than 80% in most studies, and the rate of grade 3 or 4 toxicity is very low. The use of SABR may be preferred in three circumstances: reirradiation, oligometastatic disease, and radioresistant tumours. Local ablative therapies like SABR can delay change or use of systemic therapy, preserve patients' Qol, and improve disease-free survival, progression-free survival and overall survival. Moreover, despite the potential benefit of SABR in oligometastatic disease, there is a need to establish the optial indication, RT dose fractionation, prognostic factors and optimal timing in combination with systemic therapies for SABR. This review evaluates the role of RT in BM considering these recent treatment advances. We consider the definition of complicated BM, use of single and multiple fractions RT for both complicated and uncomplicated BM, reirradiation, new treatment paradigms including local ablative treatments, oligometastatic disease, systemic therapy, physical activity and rehabilitation.
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Affiliation(s)
- André G Gouveia
- Radiation Oncology Department, Américas Centro de Oncologia Integrado, Rio de Janeiro, Brazil; Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil.
| | - Dominic C W Chan
- Department of Oncology, Princess Margaret Hospital, Hong Kong, China
| | - Peter J Hoskin
- Mount Vernon Cancer Centre, London, United Kingdom; Radiation Oncology Department, University of Manchester, United Kingdom
| | - Gustavo N Marta
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Radiation Oncology Department, Hospital Sírio Libanês, São Paulo, Brazil
| | - Fabio Trippa
- Radiation Oncology Center, Santa Maria Hospital, Terni, Italy
| | | | - Edward Chow
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Mauricio F Silva
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Radiation Oncology Unit, Santa Maria Federal University, Santa Maria, Brazil; Clínica de Radioterapia de Santa Maria, Brazil.
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Wagner A, Haag E, Joerger AK, Jost P, Combs SE, Wostrack M, Gempt J, Meyer B. Comprehensive surgical treatment strategy for spinal metastases. Sci Rep 2021; 11:7988. [PMID: 33846484 PMCID: PMC8042046 DOI: 10.1038/s41598-021-87121-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/24/2021] [Indexed: 12/31/2022] Open
Abstract
The management of patients with spinal metastases (SM) requires a multidisciplinary team of specialists involved in oncological care. Surgical management has evolved significantly over the recent years, which warrants reevaluation of its role in the oncological treatment concept. Any patient with a SM was screened for study inclusion. We report baseline characteristics, surgical procedures, complication rates, functional status and outcome of a large consecutive cohort undergoing surgical treatment according to an algorithm. 667 patients underwent 989 surgeries with a mean age of 65 years (min/max 20–94) between 2007 and 2018. The primary cancers mostly originated from the prostate (21.7%), breast (15.9%) and lung (10.0%). Surgical treatment consisted of dorsoventral stabilization in 69.5%, decompression without instrumentation in 12.5% and kyphoplasty in 18.0%. Overall survival reached 18.4 months (95% CI 9.8–26.9) and the median KPS increased by 10 within hospital stay. Surgical management of SMs should generally represent the first step of a conclusive treatment algorithm. The need to preserve long-term symptom control and biomechanical stability requires a surgical strategy currently not supported by level I evidence.
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Affiliation(s)
- Arthur Wagner
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Elena Haag
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany
| | - Ann-Kathrin Joerger
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany
| | - Philipp Jost
- Department of Hematology and Oncology, Technical University Munich School of Medicine, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University Munich School of Medicine, Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany
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Elledge CR, LaVigne AW, Fiksel J, Wright JL, McNutt T, Kleinberg LR, Hu C, Smith TJ, Zeger S, DeWeese TL, Alcorn SR. External Validation of the Bone Metastases Ensemble Trees for Survival (BMETS) Machine Learning Model to Predict Survival in Patients With Symptomatic Bone Metastases. JCO Clin Cancer Inform 2021; 5:304-314. [PMID: 33760638 DOI: 10.1200/cci.20.00128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE The Bone Metastases Ensemble Trees for Survival (BMETS) model uses a machine learning algorithm to estimate survival time following consultation for palliative radiation therapy for symptomatic bone metastases (SBM). BMETS was developed at a tertiary-care, academic medical center, but its validity and stability when applied to external data sets are unknown. PATIENTS AND METHODS Patients treated with palliative radiation therapy for SBM from May 2013 to May 2016 at two hospital-based community radiation oncology clinics were included, and medical records were retrospectively reviewed to collect model covariates and survival time. The Kaplan-Meier method was used to estimate overall survival from consultation to death or last follow-up. Model discrimination was estimated using time-dependent area under the curve (tAUC), which was calculated using survival predictions from BMETS based on the initial training data set. RESULTS A total of 216 sites of SBM were treated in 182 patients. Most common histologies were breast (27%), lung (23%), and prostate (23%). Compared with the BMETS training set, the external validation population was older (mean age, 67 v 62 years; P < .001), had more primary breast (27% v 19%; P = .03) and prostate cancer (20% v 12%; P = .01), and survived longer (median, 10.7 v 6.4 months). When the BMETS model was applied to the external data set, tAUC values at 3, 6, and 12 months were 0.82, 0.77, and 0.77, respectively. When refit with data from the combined training and external validation sets, tAUC remained > 0.79. CONCLUSION BMETS maintained high discriminative ability when applied to an external validation set and when refit with new data, supporting its generalizability, stability, and the feasibility of dynamic modeling.
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Affiliation(s)
- Christen R Elledge
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Anna W LaVigne
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jacob Fiksel
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jean L Wright
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Todd McNutt
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lawrence R Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chen Hu
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Thomas J Smith
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Scott Zeger
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Theodore L DeWeese
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sara R Alcorn
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
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Pennington Z, Ehresman J, Cottrill E, Lubelski D, Lehner K, Feghali J, Ahmed AK, Schilling A, Sciubba DM. To operate, or not to operate? Narrative review of the role of survival predictors in patient selection for operative management of patients with metastatic spine disease. J Neurosurg Spine 2021; 34:135-149. [PMID: 32916652 DOI: 10.3171/2020.6.spine20707] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/01/2020] [Indexed: 11/06/2022]
Abstract
Accurate prediction of patient survival is an essential component of the preoperative evaluation of patients with spinal metastases. Over the past quarter of a century, a number of predictors have been developed, although none have been accurate enough to be instituted as a staple of clinical practice. However, recently more comprehensive survival calculators have been published that make use of larger data sets and machine learning to predict postoperative survival among patients with spine metastases. Given the glut of calculators that have been published, the authors sought to perform a narrative review of the current literature, highlighting existing calculators along with the strengths and weaknesses of each. In doing so, they identify two "generations" of scoring systems-a first generation based on a priori factor weighting and a second generation comprising predictive tools that are developed using advanced statistical modeling and are focused on clinical deployment. In spite of recent advances, the authors found that most predictors have only a moderate ability to explain variation in patient survival. Second-generation models have a greater prognostic accuracy relative to first-generation scoring systems, but most still require external validation. Given this, it seems that there are two outstanding goals for these survival predictors, foremost being external validation of current calculators in multicenter prospective cohorts, as the majority have been developed from, and internally validated within, the same single-institution data sets. Lastly, current predictors should be modified to incorporate advances in targeted systemic therapy and radiotherapy, which have been heretofore largely ignored.
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He X, Jiao YQ, Yang XG, Hu YC. A Novel Prediction Tool for Overall Survival of Patients Living with Spinal Metastatic Disease. World Neurosurg 2020; 144:e824-e836. [PMID: 32956891 DOI: 10.1016/j.wneu.2020.09.081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To identify the significant prognostic factors for overall survival in patients with spinal metastases and to establish an online widget for predicting survival with an interactive visual approach. METHODS Patients operated for spinal metastases between 2010 and 2018 were retrospectively enrolled and were randomly divided into training and validation samples with a ratio of 7:3. Patients' characteristics were analyzed with univariate and multivariate Cox analyses to identify independent prognostic factors basing on the training sample. A shiny web tool was developed by transforming the fitted multivariable Cox model into a visual interface. Time-dependent area under the curve plot and calibration curve were generated to assess the discrimination ability and consistency of the novel model, both for the training and validation samples. RESULTS A total of 265 consecutive patients were finally included, with 185 in the training sample and 80 in the validation sample. The primary tumor types, lesion site of metastasis, visceral metastasis, Frankel grade, operation category, number of surgical segments, and the preoperative percentage of lymphocyte were demonstrated to be significantly associated with overall survival. A novel shiny model (https://yang1209xg.shinyapps.io/predictspinalmetastasis/) that could provide predicted survival curve and median survival time was established, with favorable discrimination ability and consistency between predicted and actual survival both in internal and external data, according to time-dependent area under the curve plots and calibration curves. CONCLUSIONS A user-friendly shiny app with favorable discrimination ability and consistency was released online for predicting the survival of patients with spinal metastases. A continuous survival curve and the predicted median survival time are available to guide the treatment planning.
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Affiliation(s)
- Xin He
- Department of Bone Oncology, Tianjin Hospital, Tianjin, China
| | | | - Xiong-Gang Yang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Yong-Cheng Hu
- Department of Bone Oncology, Tianjin Hospital, Tianjin, China.
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Scoring Algorithms for Predicting Survival Prognosis in Patients With Metastatic Spinal Disease: The Current Status and Future Directions. Clin Spine Surg 2020; 33:296-306. [PMID: 32604194 DOI: 10.1097/bsd.0000000000001031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Various survival scoring systems have been developed to help surgeons select the best candidates for appropriate therapies in patients with metastatic spinal disease. This study aims to discuss the current status and future directions of scoring systems for the prediction of survival prognosis in these patients. The search terms "spine metastases," "metastatic spinal disease," and "metastatic spinal cord compression" were combined with "survival prognosis," "scoring system," and "score" to elicit relevant literatures in PubMed and Embase databases. As a result, 159 articles were selected from PubMed, and 246 articles were extracted from Embase. After reviewing each article, we carefully included and analyzed 74 articles about the development and evaluation of scoring systems for predicting survival prognosis in spine metastases. In this review, those scoring systems were stratified into the historic scoring systems and the modern scoring systems on the basis of the proposed time. The historic scoring systems, including the original/revised Tokuhashi scoring system, the Bauer scoring system, the Tomita scoring system, and the Linden scoring system, and the modern scoring systems, such as the Lei scoring system, the Bartels scoring system, the Mizumoto scoring system, the Bollen scoring system, the Rades scoring system, Oswestry Spinal Risk Index, and the Choi risk calculator, were introduced and discussed in this review. Besides, the clinical effectiveness and pitfalls of the existing systems and the future directions of the next generation of scoring systems were also addressed and discussed. We recommended these scoring systems as preferable reference tools to help doctors to select surgical candidates. In patients with long-term life expectancy, radical surgery, such as wide or marginal excision, can be considered in patients with neurological deficits, spine instability, or severe back pain. Besides, with the advancement and improvement of medical technologies, surgical procedures are changing, which can affect surgical indications such as vertebroplasty, minimal invasive surgery, and percutaneous stabilization, which can also be used in patients with spine instability or severe back pain, and do not require much recovery; hence, they can even be used in patients with relative short-term life expectancy. However, the decision about the treatment of patients with metastatic spinal disease is so complicated and should never rely on prognostic scores alone. The final therapeutic decision should be made by interdisciplinary corporations of oncologists, radiologists, and spinal surgeons. Besides, individual intentions should be respected.
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Nater A, Chuang J, Liu K, Quraishi NA, Pasku D, Wilson JR, Fehlings MG. A Personalized Medicine Approach for the Management of Spinal Metastases with Cord Compression: Development of a Novel Clinical Prediction Model for Postoperative Survival and Quality of Life. World Neurosurg 2020; 140:654-663.e13. [PMID: 32797992 DOI: 10.1016/j.wneu.2020.03.098] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 03/15/2020] [Indexed: 11/16/2022]
Abstract
Surgery should be considered for patients with metastatic epidural spinal cord compression (MESCC) with a life expectancy of ≥3 months. Given the heterogeneity of the clinical presentation and outcomes, clinical prognostic models (CPMs) can assist in tailoring a personalized medicine approach to optimize surgical decision-making. We aimed to develop and internally validate the first CPM of health-related quality of life (HRQoL) and a novel CPM to predict the survival of patients with MESCC treated surgically. Using data from 258 patients (AOSpine North America MESCC study and Nottingham MESCC registry), we created 1-year survival and HRQoL CPMs using a Cox model and logistic regression analysis with manual backward elimination. The outcome measure for HRQoL was the minimal clinical important difference in EuroQol 5-dimension questionnaire scores. Internal validation involved 200 bootstrap iterations, and calibration and discrimination were evaluated. Longer survival was associated with a higher SF-36 physical component score (hazard ratio [HR], 0.96). In contrast, primary tumor other than breast, thyroid, or prostate (unfavorable: HR, 2.57; other: HR, 1.20), organ metastasis (HR, 1.51), male sex (HR, 1.58), and preoperative radiotherapy (HR, 1.53) were not (c-statistic, 0.69; 95% confidence interval, 0.64-0.73). Karnofsky performance status <70% (odds ratio [OR], 2.50), living in North America (OR, 4.06), SF-36 physical component score (OR, 0.95) and SF-36 mental component score (OR, 0.96) were associated with the likelihood of achieving a minimal clinical important difference improvement in the EuroQol 5-Dimension Questionnaire score at 3 months (c-statistic, 0.74; 95% confidence interval, 0.68-0.79). The calibration for both CPMs was very good. We developed and internally validated the first CPMs of survival and HRQoL at 3 months postoperatively in patients with MESCC using the TRIPOD (transparent reporting of a multivariable prediction model for individual prognosis or diagnosis) guidelines. A web-based calculator is available (available at: http://spine-met.com) to assist with clinical decision-making.
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Affiliation(s)
- Anick Nater
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Junior Chuang
- Biostatistics Division, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Kuan Liu
- Biostatistics Division, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Nasir A Quraishi
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospital National Health Service Trust, Nottingham, United Kingdom
| | - Dritan Pasku
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospital National Health Service Trust, Nottingham, United Kingdom
| | - Jefferson R Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Michael G Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, Ontario, Canada.
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Cook WH, Baker JF. Retrospective evaluation of prognostic factors in metastatic spine disease: serum albumin and primary tumour type are key. ANZ J Surg 2020; 90:1070-1074. [DOI: 10.1111/ans.15821] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 02/15/2020] [Accepted: 02/25/2020] [Indexed: 12/26/2022]
Affiliation(s)
- William H. Cook
- Department of Surgery, Faculty of Medical and Health SciencesThe University of Auckland Auckland New Zealand
| | - Joseph F. Baker
- Department of Surgery, Faculty of Medical and Health SciencesThe University of Auckland Auckland New Zealand
- Department of Orthopaedic SurgeryWaikato Hospital Hamilton New Zealand
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CORTEZ PAULOROGÉRIO. SPINAL METASTASIS: DIAGNOSIS, TREATMENT AND PROGNOSIS - INTEGRATIVE REVIEW FROM 2012 TO 2017. COLUNA/COLUMNA 2020. [DOI: 10.1590/s1808-185120201901192641] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
ABSTRACT Care of the patient with spinal metastasis is challenging. The topic of this article is the treatment and prognosis of spinal metastases, aiming to enumerate and analyze literature that addresses this treatment and prognosis. The methodology used was an integrative review in the Virtual Health Library. Nineteen articles were identified demonstrating that there is research and scientific production in this area. The thematic units and their categories are: treatment decision - prognostic scales or clinical neurological evaluation; types of treatment - minimally invasive and/or traditional; and effectiveness of prognostic scales higher or lower probability of success, which provide insight into the different possibilities of patient evaluation and their applicability in practice. When making the diagnosis, planning the treatment, and establishing a prognosis, the professional must be in sync with current precepts and act based on the objective and subjective characteristics of the patients, such as beliefs and values, which although immeasurable, influence the survival and the effectiveness of treatment. Level of evidence I; Integrative Review.
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Affiliation(s)
- PAULO ROGÉRIO CORTEZ
- Universidade Federal Fluminense, Brazil; Hospital Estadual Azevedo Lima, Brazil; Hospital Federal do Andaraí, Brazil; Centro de Saúde da Coluna, Brazil
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Westermann L, Olivier AC, Samel C, Eysel P, Herren C, Sircar K, Zarghooni K. Analysis of seven prognostic scores in patients with surgically treated epidural metastatic spine disease. Acta Neurochir (Wien) 2020; 162:109-119. [PMID: 31781995 DOI: 10.1007/s00701-019-04115-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 10/21/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Prognostic scores have been proposed to guide the treatment of patients with metastatic spine disease (MSD), but their accuracy and usefulness are controversial. The aim of this study was to evaluate seven such prognostic scoring systems. The following prognostic scores were compared: Tomita, Van der Linden (VDL), Bauer modified (BM), Oswestry Spinal Risk Index (OSRI), Tokuhashi original (T90), Tokuhashi revised (TR05), and modified Tokuhashi revised (TR17). METHODS We retrospectively reviewed all our patients who underwent surgery for spinal metastases, February 2008-January 2015. We classified all 223 patients into the predicted survival-time categories of each of the 7 scoring systems and then tallied how often this was correct vis-à-vis the actual survival time. Accuracy was also assessed using receiver operating characteristic (ROC) analysis at 1, 3, and 12 months. RESULTS The median (95% CI) survival of the 223 patients was 13.6 (7.9-19.3) months. A groupwise ROC analysis showed sufficient accuracy for 3-month survival only for TR17 (area under the curve [AUC] 0.71) and for 1-year survival for T90 (AUC 0.73), TR05 (AUC 0.76), TR17 (AUC 0.76), Tomita (AUC 0.77), and OSRI (AUC 0.71). A pointwise ROC score analysis showed poor prognostic ability for short-term survival (1 and 3 months) with sufficient accuracy for T90 (AUC 0.71), TR05 (AUC 0.71), TR17 (AUC 0.71), and the Tomita score (AUC 0.77) for 1-year survival. CONCLUSION The TR17 was the only prognostic system with acceptable performance here. More sophisticated assessment tools are required to keep up with present and future changes in tumor diagnostics and treatment.
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Affiliation(s)
- Leonard Westermann
- Department of Orthopedics and Traumatology, Faculty of Medicine and University Hospital, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Alain Christoph Olivier
- Department of Orthopedics and Traumatology, Faculty of Medicine and University Hospital, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
| | - Christina Samel
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Peer Eysel
- Department of Orthopedics and Traumatology, Faculty of Medicine and University Hospital, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Christian Herren
- Department of Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Krishnan Sircar
- Department of Orthopedics and Traumatology, Faculty of Medicine and University Hospital, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Kourosh Zarghooni
- Department of Orthopedics and Traumatology, Faculty of Medicine and University Hospital, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
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Yang XG, Feng JT, Wang F, He X, Zhang H, Yang L, Zhang HR, Hu YC. Development and validation of a prognostic nomogram for the overall survival of patients living with spinal metastases. J Neurooncol 2019; 145:167-176. [DOI: 10.1007/s11060-019-03284-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/31/2019] [Indexed: 11/29/2022]
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Bouthors C, Prost S, Court C, Blondel B, Charles YP, Fuentes S, Mousselard HP, Mazel C, Flouzat-Lachaniette CH, Bonnevialle P, Saihlan F. Outcomes of surgical treatments of spinal metastases: a prospective study. Support Care Cancer 2019; 28:2127-2135. [PMID: 31396747 DOI: 10.1007/s00520-019-05015-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 07/30/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Owing to recent advances in cancer therapy, updated data are required for clinicians counselling patients on treatment of spinal metastases. OBJECTIVE To analyse the outcomes of surgical treatments of spinal metastases. METHODS Prospective and multicentric study that included consecutively patients operated on for spinal metastases between January 2016 and January 2017. Overall survival was calculated with the Kaplan-Meier method. Cox proportional hazard model was used to calculate hazard ratio (HR) analysing mortality risk according to preoperative Karnofsky performance status (KPS), mobility level and neurological status. RESULTS A total of 252 patients were included (145 males, 107 females) aged a mean 63.3 years. Median survival was 450 days. Primary cancer sites were lung (21%) and breast (19%). Multiple spinal metastases involved 122 patients (48%). Concomitant skeletal and visceral metastases were noted in 90 patients (36%). Main procedure was laminectomy and posterior fixation (57%). Overall, pain and mobility level were improved postoperatively. Most patients had normal preoperative motor function (50%) and remained so postoperatively. Patients "bedbound" on admission were the less likely to recover. In-hospital death rate was 2.4% (three disease progression, one septic shock, one pneumonia, one pulmonary embolism). Complication rate was 33%, deep wound infection was the most frequent aetiology. Higher mortality was observed in patients with poorest preoperative KPS (KPS 0-40%, HR = 3.1, p < 0.001) and mobility level ("bedbound", HR = 2.16, p < 0.001). Survival seemed also to be linked to preoperative neurological function. CONCLUSION Surgical treatments helped maintain reasonable condition for patients with spinal metastases. Intervention should be offered before patients' condition worsen to ensure better outcomes.
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Affiliation(s)
- C Bouthors
- Orthopedic and Traumatology Surgery Department, Bicetre University Hospital, AP-HP, Paris XI University, 78 Rue du Général Leclerc, 94275, Le Kremlin-Bicêtre, France.
| | - S Prost
- Orthopedic and Traumatology Surgery Department, La Timone Hospital, AP-HM, Aix Marseille University, CNRS ISM, 264 rue Saint Pierre, 13005, Marseille, France
| | - C Court
- Orthopedic and Traumatology Surgery Department, Bicetre University Hospital, AP-HP, Paris XI University, 78 Rue du Général Leclerc, 94275, Le Kremlin-Bicêtre, France
| | - B Blondel
- Orthopedic and Traumatology Surgery Department, La Timone Hospital, AP-HM, Aix Marseille University, CNRS ISM, 264 rue Saint Pierre, 13005, Marseille, France
| | - Y P Charles
- Orthopedic and Traumatology Surgery Department, Hautepierre Hospital, Strasbourg University Hospital, Avenue Molière, 67200, Strasbourg, France
| | - S Fuentes
- Neurosurgery Department, La Timone Hospital, AP-HM, Aix Marseille University, 264 rue Saint Pierre, 13005, Marseille, France
| | - H P Mousselard
- Orthopedic and traumatology surgery department, La Pitié-Salpétrière Hospital, AP-HP, Parix VI University, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - C Mazel
- Orthopedic and traumatology surgery department, Institut Mutualiste Montsouris, Paris V University, 42 Boulevard Jourdan, 75014, Paris, France
| | - C H Flouzat-Lachaniette
- Orthopedic and traumatology surgery department, Mondor Hospital, APHP, Paris XII University, 51 Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France
| | - P Bonnevialle
- Orthopedic and traumatology surgery department, Riquet Pierre-Paul Hospital, Place du Docteur Baylac,, TSA 40031-31059, Toulouse cedex 9, France
| | - F Saihlan
- Orthopedic and traumatology surgery department, Cochin Hospital, APHP, Paris V University, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France
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[Metastatic breast cancer in the spine : Molecular predictors for choosing adequate treatment strategies]. DER ORTHOPADE 2019; 47:594-603. [PMID: 29487982 DOI: 10.1007/s00132-018-3540-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Breast cancer is the most common malignancy affecting women and the spinal column is most likely affected by metastases. Modern oncologic treatment options have significantly prolonged survival times in the last decade. Therefore, treatment of vertebral metastases has been of special interest in spine surgery. Different scores are described to evaluate prognosis and to choose correct treatment strategies, which however only differentiate tumor entities and not specific tumor phenotypes. Breast cancer has been classified into five intrinsic subtypes with different survival rates since the turn of the millennium. The aim of this review was to describe molecular predictors of breast cancer malignancy and to better estimate expected survival times and invasiveness of therapies with regard to spinal metastases.
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Mohd Rothi I, Deverall HH, Baker JF. The modified Frailty Index does not correlate with survival in surgically-treated patients with metastatic spine disease. J Clin Neurosci 2019; 66:178-181. [PMID: 31101585 DOI: 10.1016/j.jocn.2019.04.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 02/20/2019] [Accepted: 04/28/2019] [Indexed: 01/30/2023]
Abstract
With the increasing burden of metastatic spinal disease there is ever-more pressure on the health system to provide optimal management. Multiple treatment modalities, including surgical intervention, are available. Multiple prognostic scoring systems have been developed to aid both clinician and patient in making the best decision for each individual. The modified Frailty Index (mFI) has not been assessed for its correlation with survival in patients treated for metastatic spine disease. A retrospective review of a patients undergoing surgery for metastatic spine disease at a tertiary referral centre was performed and a comparison was made between the mFI and previously established disease-specific prognostic scores (revised Tokuhashi, modified Bauer and Tomita scores and the Oswestry Spine Risk Index). 41 patients were included over a 5-year period. 38 deceased by the end of the study period with a 30-day mortality of 14.6% and a 1-year mortality of 73.2%. The mFI poorly correlated with survival. Out of the four established scoring system, the OSRI had the best correlation. The mFI did not correlate with survival in this cohort of surgically treated patients with metastatic spinal disease and is best used as a selection tool for surgery. Dedicated prognostic tools can be selected appropriate to the institution experience and set-up.
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Affiliation(s)
| | | | - Joseph F Baker
- Waikato Hospital, New Zealand; University of Auckland, New Zealand
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Karhade AV, Shin JH, Schwab JH. Prognostic models for spinal metastatic disease: evolution of methodologies, limitations, and future opportunities. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:219. [PMID: 31297384 DOI: 10.21037/atm.2019.04.87] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Advances in cancer biology and therapy have increased survival of metastatic disease patients and, in turn, the rates of metastatic epidural spinal cord compression (MESCC). Surgery can improve patient quality of life, but accurate estimation of postoperative survival is critical for appropriate patient selection, multidisciplinary management, and shared decision making. Survival estimation on the basis of clinician judgement alone has been shown to be inaccurate and unreliable. Numerous prognostic scoring systems have been developed to address this need but the inputs to these models, the modeling methodologies, and the model outputs have evolved significantly over time. Here we discuss the available scoring systems, existing limitations, and future opportunities.
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Affiliation(s)
- Aditya V Karhade
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph H Schwab
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Development and Validation of a Novel Survival Prediction Model in Patients With Spinal Metastasis From Non-small Cell Lung Cancer. Spine (Phila Pa 1976) 2019; 44:246-257. [PMID: 30059487 DOI: 10.1097/brs.0000000000002816] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE The aim of this study was to develop a model for predicting survival of patients with non-small cell lung cancer (NSCLC) spinal metastasis and compare its accuracy with the existing scoring systems. SUMMARY OF BACKGROUND DATA Spinal metastasis is commonly seen in advanced NSCLC and usually associated with poor survival prognosis. METHODS A total of 376 patients with NSCLC spinal metastases admitted to our institution from January 2010 to October 2016 were enrolled. They were randomly assigned at a 3:1 ratio to a training cohort (n = 282) and a validation cohort (n = 94). A nomogram for survival prediction was established by identifying and integrating significant prognostic factors, and then subjected to bootstrap validation in both training and validation cohorts. The discrimination was measured by concordance index (C-index). Predictive accuracy was compared with three existing models by the receiver-operating characteristic curve (ROC) and area under ROC in both training and validation cohorts. RESULTS Six independent prognostic factors including sex (P = 0.008), the presence of visceral metastasis (P = 0.008), the number of metastases in the vertebral body (P = 0.011), Frankel score (P < 0.001), D-dimer (P = 0.002), and sensitive epidermal growth factor receptor mutation (p < 0.001) were identified and entered into the nomogram. The calibration curves for probability of 3-, 6-, 12- and, 24-month overall survival showed good agreement between the predictive risk and the actual risk. The C-index of the nomogram was 0.708 (95% confidence interval [CI], 0.674-0.742) in the training cohort and 0.683 (95% CI, 0.619-0.747) in the validation cohort. Model comparison showed that this nomogram had better predictive accuracy than the Tomita et al, Tokuhashi et al, and Schwab et al scoring systems (P < 0.05 in the training cohort). CONCLUSION We established and validated a novel nomogram that could be used to predict the survival outcome of patients with NSCLC spinal metastasis, thus helping clinicians in decision making and individualized care planning of such patients. LEVEL OF EVIDENCE 4.
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Prediction Accuracy of Common Prognostic Scoring Systems for Metastatic Spine Disease: Results of a Prospective International Multicentre Study of 1469 Patients. Spine (Phila Pa 1976) 2018; 43:1678-1684. [PMID: 30422958 DOI: 10.1097/brs.0000000000002576] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective multicenter cohort study. OBJECTIVE To assess the clinical accuracy of six commonly cited prognostic scoring systems for patients with spinal metastases. SUMMARY OF BACKGROUND DATA There are presently several available methods for the estimation of prognosis in metastatic spinal disease, but none are universally accepted by surgeons for clinical use. These scoring systems have not been rigorously tested and validated in large datasets to see if they are reliable enough to inform day-to-day patient management decisions. We tested these scoring systems in a large cohort of patients. A total of 1469 patients were recruited into a secure internet database, and prospectively collected data were analyzed to assess the accuracy of published prognostic scoring systems. METHODS We assessed six prognostic scoring systems, described by the first authors Tomita, Tokuhashi, Bauer, van der Linden, Rades, and Bollen. Kaplan-Meier survival estimates were created for different patient subgroups as described in the original publications. Harrell's C-statistic was calculated for the survival estimates, to assess the concordance between estimated and actual survival. RESULTS All the prognostic scoring systems tested were able to categorize patients into separate prognostic groups with different overall survivals. However none of the scores were able to achieve "good concordance" as assessed by Harrell's C-statistic. The score of Bollen and colleagues was found to be the most accurate, with a Harrell's C-statistic of 0.66. CONCLUSION No prognostic scoring system was found to have a good predictive value. The scores of Bollen and Tomita were the most effective with Harrell's C-statistic of 0.66 and 0.65, respectively. Prognostic scoring systems are calculated using data from previous years, and are subject to inaccuracies as treatments advance in the interim. We suggest that other methods of assessing prognosis should be explored, such as prognostic risk calculation. LEVEL OF EVIDENCE 3.
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Cassidy JT, Baker JF, Lenehan B. The Role of Prognostic Scoring Systems in Assessing Surgical Candidacy for Patients With Vertebral Metastasis: A Narrative Review. Global Spine J 2018; 8:638-651. [PMID: 30202719 PMCID: PMC6125937 DOI: 10.1177/2192568217750125] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVES To review the relevant literature regarding scoring systems for vertebral metastases and quantify their role in contemporary orthopedic practice. METHODS A literature search of PubMed, Google Scholar, and Embase was performed on February 7, 2017. Eight scoring systems were selected for detailed review-7 of which were scores focused solely on patient prognosis (Tokuhashi, Tomita, Bauer, Oswestry Spinal Risk Index, Van der Linden, Rades, and Katagiri). The eighth system reviewed was the Spinal Instability Neoplastic Score, which examines for impending spinal instability in patients with vertebral metastases and represents a novel approach compared with hitherto scoring systems. RESULTS The Bauer and Oswestry Spinal Risk Index have the most accurate prognostic predictive ability, with the newer Oswestry Spinal Risk Index being favored by the contemporary literature as it demands less investigation and is therefore more readily accessible. There was a growing trend in studies designed to customize scoring systems for individual cancer pathological subtypes. The Spinal Instability Neoplastic Score shows good reliability for predicting instability among surgeons and oncologists. CONCLUSIONS The increased understanding of cancer pathology and subsequent development of customized treatments has led to prolonged survival. For patients with vertebral metastases, this affects surgical candidacy not only on the basis of prognosis but also provides prolonged opportunity for the development of spinal instability. Scoring systems have a useful guidance role in these deciding for/against surgical intervention, but in order to remain contemporary ongoing review, development, and revalidation is mandatory.
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Affiliation(s)
- John Tristan Cassidy
- University Hospital Limerick, Limerick, Ireland,John Tristan Cassidy, Department of Trauma & Orthopaedic Surgery, University Hospital Limerick, Limerick, Ireland.
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Abstract
Due to a worldwide increase of cancer incidence and a longer life expectancy of patients with metastatic cancer, a rise in the incidence of symptomatic vertebral metastases has been observed. Metastatic spinal disease is one of the most dreaded complications of cancer as it is not only associated with severe pain, but also with paralysis, sensory loss, sexual dysfunction, urinary and fecal incontinency when the neurologic elements are compressed. Rapid diagnosis and treatment have been shown to improve both the quality and length of remaining life. This chapter on vertebral metastases with epidural disease and intramedullary spinal metastases will be discussed in terms of epidemiology, pathophysiology, demographics, clinical presentation, diagnosis, and management. With respect to treatment options, our review will summarize the evolution of conventional palliative radiation to modern stereotactic body radiotherapy for spinal metastases and the surgical evolution from traditional open procedures to minimally invasive spine surgery. Lastly, we will review the most common clinical prediction and decision rules, framework and algorithms, and guidelines that have been developed to guide treatment decision making.
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Nater A, Tetreault LA, Kopjar B, Arnold PM, Dekutoski MB, Finkelstein JA, Fisher CG, France JC, Gokaslan ZL, Rhines LD, Rose PS, Sahgal A, Schuster JM, Vaccaro AR, Fehlings MG. Predictive factors of survival in a surgical series of metastatic epidural spinal cord compression and complete external validation of 8 multivariate models of survival in a prospective North American multicenter study. Cancer 2018; 124:3536-3550. [PMID: 29975401 DOI: 10.1002/cncr.31585] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 01/30/2018] [Accepted: 03/26/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Anick Nater
- Department of Neurosurgery, Toronto Western Hospital, University Health Network; University of Toronto; Toronto Ontario Canada
| | - Lindsay A. Tetreault
- Department of Neurosurgery, Toronto Western Hospital, University Health Network; University of Toronto; Toronto Ontario Canada
- Graduate Entry Medicine; University College Cork; Cork Ireland
| | - Branko Kopjar
- Department of Health Services, University of Washington; Seattle Washington
| | - Paul M. Arnold
- Department of Neurosurgery, University of Kansas; Kansas City Kansas
| | - Mark B. Dekutoski
- Department of Orthopaedic Surgery, CORE Institute; Sun City West Arizona
| | - Joel A. Finkelstein
- Department of Orthopaedic Surgery, Sunnybrook Health Sciences Center; Toronto Ontario Canada
| | - Charles G. Fisher
- Department of Orthopaedic Surgery, University of British Columbia; Vancouver British Columbia Canada
- Department of Orthopaedic Surgery, Vancouver Coastal Health; Vancouver British Columbia Canada
| | - John C. France
- Department of Orthopaedic Surgery, West Virginia University; Morgantown West Virginia
| | - Ziya L. Gokaslan
- Department of Neurosurgery, Warren Alpert Medical School of Brown University; Providence Rhode Island
| | - Laurence D. Rhines
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Peter S. Rose
- Department of Orthopaedic Surgery, Mayo Clinic; Rochester Minnesota
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Center; Toronto, Ontario Canada
| | - James M. Schuster
- Department of Neurosurgery, University of Pennsylvania; Philadelphia Pennsylvania
| | - Alexander R. Vaccaro
- Department of Orthopaedic Surgery, Thomas Jefferson University; Philadelphia Pennsylvania
| | - Michael G. Fehlings
- Department of Neurosurgery, Toronto Western Hospital, University Health Network; University of Toronto; Toronto Ontario Canada
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Evaluation of Prognostic Factors and Proposed Changes to the Modified Tokuhashi Score in Patients With Spinal Metastases From Breast Cancer. Spine (Phila Pa 1976) 2018; 43:512-519. [PMID: 28749856 DOI: 10.1097/brs.0000000000002350] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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 all patients with histologically confirmed breast cancer spinal metastases presenting to a single institution between May 2001 and April 2012. OBJECTIVES The aim of this study was to investigate whether the 2014mT is more accurate than the 2005mT. SUMMARY OF BACKGROUND DATA The commonly used 2005 modified Tokuhashi score (2005mT) has become more inaccurate as oncologists move toward treating tumors according to their molecular and genomic profile, rather than their tissue-of-origin. In attempts to improve the accuracy of the 2005mT, a revised score (2014mT) was published, suggesting that hormone receptor negative and triple-negative breast cancer patients be given a modified Tokuhashi histological score of 3 rather than 5. METHODS Demographic characteristics, tumor receptor status, clinical findings in relation to the primary tumor and its metastases, and actual survival time were collated. The 2005mT was compared with the 2014mT. Univariate and multivariate Cox regression analyses were used to evaluate the influence of each parameter on survival, and receiver operating characteristic curves were used to determine predictive values of each score version. RESULTS Of the 185 patients included, 32 underwent operative treatment, while 153 were managed nonoperatively for their spinal metastases. The overall cohort had a median survival time of 24 months following the diagnosis of spinal metastases, with a 6-month survival rate of 90%. Hormone, HER2 and triple-negative receptor statuses were significant predictors of poorer survival upon multivariate analysis (P = 0.004, P = 0.007, P < 0.001, and P < 0.001, respectively). Age, the original Tokuhashi score components, previous breast surgery for cancer, previous radiotherapy to the breast, previous radiotherapy to the spine, previous chemotherapy, and previous immunotherapy were not significant. At 6 months, the 2005mT AUROC was 0.62, while that of the 2014mT was 0.64 (P = 0.5394). CONCLUSION Tumor histological subtype is crucial when prognosticating the survival of patients with breast cancer spinal metastases. Although the 2014mT was marginally more accurate than the 2005mT, its predictive ability remains poor. LEVEL OF EVIDENCE 3.
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The Influence of Histologic Subtype in Predicting Survival of Lung Cancer Patients With Spinal Metastases. Clin Spine Surg 2018; 31:E1-E7. [PMID: 27875414 DOI: 10.1097/bsd.0000000000000475] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective analysis. SUMMARY OF BACKGROUND DATA Recent advancements in systemic treatment of lung cancer have significantly improved the survival of patients with certain histolopathologic and molecular subtypes. Existing prognostic scores do not account for this and patients with lung cancer spinal metastases are grouped together as poor prognostic candidates, and consequently, some may be inappropriately denied palliative spine surgery. OBJECTIVE The objective of the study was to study whether the expected survival in patients with lung cancer spinal metastases is affected by histolopathologic and molecular subtypes in the context of modern systemic therapy. MATERIALS AND METHODS We retrospectively reviewed all patients with histologically confirmed lung cancer treated for spinal metastases at our institution between 2001 and 2012. Patients' demographics, histopathologic details, treatment modalities, and survival data were collected. The primary outcome was survival from time of spinal metastases diagnosis. The Cox regression analysis was used to evaluate the influence of tumor histology, molecular profile and treatment modality on survival. The Kaplan-Meier survival analysis was conducted to compare lung cancer subtypes, as well as various treatment regimens. RESULTS Out of 180 patients, 51 underwent surgery for spinal metastases. Female sex (P=0.019), absence of palsy (P=0.023), good Karnofsky performance scores (P<0.001), and non-small cell lung cancer (NSCLC) (P=0.002) were favorable prognostic factors. Patients who received systemic therapy, including tyrosine kinase inhibitors, platinum doublet chemotherapy, or both showed increased survival (P<0.01). The median survival time was 2.40 months [95% confidence interval (CI), 2.13-2.68] in the small cell lung cancer cohort, with no patients surviving past a year; 5.10 months (95% CI, 3.78-6.41) in the NSCLC cohort, with 25.9% 1-year survival; and 13.3 months (95% CI, 2.26-24.40) in adenocarcinoma patients who received both tyrosine kinase inhibitors and platinum doublet therapy, with 50.0% 1-year survival. CONCLUSIONS NSCLC, systemic therapy, female sex, absence of palsy and good Karnofsky performance scores are all independent favorable prognostic factors for patients with lung cancer spinal metastases. These should be routinely considered during prognostication.
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Dosani M, Tyldesley S, Bakos B, Hamm J, Kong T, Lucas S, Wong J, Liu M, Hamilton S. The TEACHH model to predict life expectancy in patients presenting for palliative spine radiotherapy: external validation and comparison with alternate models. Support Care Cancer 2018; 26:2217-2227. [DOI: 10.1007/s00520-018-4064-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 01/22/2018] [Indexed: 12/24/2022]
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Turner I, Kennedy J, Morris S, Crockard A, Choi D. Surgery and Radiotherapy for Symptomatic Spinal Metastases Is More Cost Effective Than Radiotherapy Alone: A Cost Utility Analysis in a U.K. Spinal Center. World Neurosurg 2018; 109:e389-e397. [DOI: 10.1016/j.wneu.2017.09.189] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 09/26/2017] [Accepted: 09/27/2017] [Indexed: 10/18/2022]
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Tokuhashi Y, Uei H, Oshima M. Classification and scoring systems for metastatic spine tumors: a literature review. Spine Surg Relat Res 2017; 1:44-55. [PMID: 31440612 PMCID: PMC6698555 DOI: 10.22603/ssrr.1.2016-0021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 12/20/2016] [Indexed: 01/29/2023] Open
Abstract
Introduction Accurate evaluation of metastasis and life prognosis is essential for selecting a suitable therapeutic strategy for metastatic spine tumors owing to limitations in treatment options. For this purpose, various classification, evaluation, and scoring systems have been developed. Methods Classification, evaluation, and scoring systems for metastatic spine tumors reported to date were identified by performing a literature search on PubMed. We reviewed the most cited classifications and scorings before 2009, and all classifications and scorings reported after 2010 from the search results. Results Six classifications and 23 scorings were reviewed. The classification/evaluation methods are divided into 1) anatomical classification/evaluation methods, 2) evaluation methods for neurological symptoms/instability, and 3) scoring systems for predicting life expectancy. The first 2 were useful for the planning and evaluation of surgical indications. Scoring systems for life prognosis also permitted rough prediction of the outcomes and were useful for the selection of a suitable treatment. However, variation of the patient background, diversity of adopted prognostic factors, and the absence of scoring systems that could predict the outcome with an accuracy of 90% or higher introduced some limitations. Conclusion The identified classification, evaluation, and scoring systems have been generally useful for treatment strategies. However, we emphasize the necessity of multidisciplinary development and revision of classification and evaluation methods to adapt to the prolongation of survival associated with increased diversity and improvement of treatment options.
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Affiliation(s)
- Yasuaki Tokuhashi
- Department of Orthopedic Surgery, Nihon University School of Medicine, Japan
| | - Hiroshi Uei
- Department of Orthopedic Surgery, Nihon University School of Medicine, Japan
| | - Masashi Oshima
- Department of Orthopedic Surgery, Nihon University School of Medicine, Japan
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Bollen L, Jacobs WCH, Van der Linden YM, Van der Hel O, Taal W, Dijkstra PDS. A systematic review of prognostic factors predicting survival in patients with spinal bone metastases. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:799-805. [DOI: 10.1007/s00586-017-5320-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 09/02/2017] [Accepted: 09/30/2017] [Indexed: 02/02/2023]
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A revision of the Tokuhashi revised score improves the prognostic ability in patients with metastatic spinal cord compression. J Cancer Res Clin Oncol 2017; 144:33-38. [DOI: 10.1007/s00432-017-2519-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 09/08/2017] [Indexed: 02/01/2023]
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Kumar N, Malhotra R, Maharajan K, Zaw AS, Wu PH, Makandura MC, Po Liu GK, Thambiah J, Wong HK. Metastatic Spine Tumor Surgery: A Comparative Study of Minimally Invasive Approach Using Percutaneous Pedicle Screws Fixation Versus Open Approach. Clin Spine Surg 2017; 30:E1015-E1021. [PMID: 27352374 DOI: 10.1097/bsd.0000000000000400] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Prospective cohort study. SUMMARY OF BACKGROUND DATA Minimally invasive spinal surgery (MISS) has been gaining recognition in patients with metastatic spine disease (MSD). The advantages are reduction in blood loss, hospital stay, and postoperative morbidity. Most of the studies were case series with very few comparing the outcomes of MISS to open approaches. OBJECTIVE To evaluate and compare the clinical and perioperative outcomes of MISS versus open approach in patients with symptomatic MSD, who underwent posterior spinal stabilization and/or decompression. PATIENTS AND METHODS Our study included 45 MSD patients; 27 managed by MISS and 18 by open approach. All patients had MSD presenting with symptoms of neurological deficit, spinal instability, or both. Preoperative, intraoperative, and postoperative data were collected for comparison of the 2 approaches. All patients were followed up until the end of study period (maximum up to 4 years from time of surgery) or till their demise. The clinical outcome measures were pain control, neurological and functional status, whereas perioperative outcomes were blood loss, operative time, length of hospital stay, and time taken to initiate radiotherapy/chemotherapy after index surgery. RESULTS Majority of patients in both groups showed improvement in pain, neurological status, independent ambulation, and ECOG score in the postoperative period with no significant differences between the 2 groups. There was a significant reduction in intraoperative blood loss (621 mL less, P<0.001) in the MISS group. The average time to initiate radiotherapy after surgery was 13 days (range, 12-16 d) in MISS and 24 days (range, 16-40 d) in the open group. This difference was statistically significant (P<0.001). Operative time and duration of hospital stay were also favorable in the MISS group, although the differences were not significant. CONCLUSIONS MISS is comparable with open approach demonstrating similar improvements in clinical outcomes, that is pain control, neurological and functional status. MISS approaches have also shown promising results due to lesser intraoperative blood loss and allowing earlier radiotherapy/chemotherapy.
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Affiliation(s)
- Naresh Kumar
- Department of Orthopaedic Surgery, National University Health System, Singapore, Singapore
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Abstract
STUDY DESIGN A retrospective data collection study with application of metastatic spine scoring systems. OBJECTIVES To apply the Tomita and revised Tokuhashi scoring systems to a surgical cohort at a single academic institution and analyze spine-related surgical morbidity and mortality rates. SUMMARY OF BACKGROUND DATA Surgical management of metastatic spine patients requires tools that can accurately predict patient survival, as well as knowledge of morbidity and mortality rates. METHODS An Oregon Health & Science University (OHSU) Spine Center surgical database was queried (years 2002-2010) to identify patients with an ICD-9 code indicative of metastatic spine disease. Patients whose only surgical treatment was vertebral augmentation were not included. Scatter plots of survival versus the Tomita and revised Tokuhashi metastatic spine scoring systems were statistically analyzed. Spine-related morbidity and mortality rates were calculated. RESULTS Sixty-eight patients were identified: 45 patients' (30 male patients, mean age 45 y) medical records included operative, morbidity, and mortality statistic data and 38 (26 male patients, mean age 54 y) contained complete metastatic spine scoring system data. Of the 38 deceased spine metastatic patients, 8 had renal cell, 7 lung, 4 breast, 2 chondrosarcoma, 2 prostate, 11 other, and 4 unknown primary cancers. Linear regression analysis revealed R values of 0.2570 and 0.2009 for the revised Tokuhashi and Tomita scoring systems, respectively. Overall transfusion, infection, morbidity, and mortality rates were 33% and 9%, and 42% and 9%, respectively. CONCLUSIONS Application of metastatic prognostic scoring systems to a retrospective surgical cohort revealed an overall poor correlation with the Tomita and revised Tokuhashi predictive survival models. Morbidity and mortality rates concur with those in the medical literature. This study underscores the difficulty in utilizing metastatic spine scoring systems to predict patient survival. We believe a scoring system based on cancer type is needed to account for changes in treatment paradigms with improved patient survival over time.
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Kumar N, Malhotra R, Zaw A, Maharajan K, Naresh N, Kumar A, Vellayappan B. Evolution in treatment strategy for metastatic spine disease: Presently evolving modalities. Eur J Surg Oncol 2017; 43:1784-1801. [DOI: 10.1016/j.ejso.2017.05.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 03/07/2017] [Accepted: 05/05/2017] [Indexed: 01/01/2023] Open
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Piggott RP, Curtin M, Munigangaiah S, Jadaan M, McCabe JP, Devitt A. Sternal metastasis - the forgotten column and its effect on thoracic spine stability. World J Orthop 2017; 8:455-460. [PMID: 28660136 PMCID: PMC5478487 DOI: 10.5312/wjo.v8.i6.455] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 04/01/2017] [Accepted: 04/24/2017] [Indexed: 02/06/2023] Open
Abstract
Sternal metastases are not studied extensively in the literature. There is a paucity of information on their role in metastatic disease. The concept of the fourth column was described by Berg in 1993, and has been proven in case report, clinically and biomechanical studies. The role of the sternum as a support to the thoracic spine is well documented in the trauma patients, but not much is known about its role in cancer patients. This review examines what is known on the role of the fourth column. Following this we have identified two likely scenarios that sternal metastases may impact management: (1) sternal pathological fracture increases the mobility of the semi-rigid thorax with the loss of the biomechanical support of the sternum-rib-thoracic spine complex; and (2) a sternal metastasis increases the risk of fracture, and while being medical treated the thoracic spine should be monitored for acute kyphosis and neurological injury secondarily to the insufficiency of the fourth column.
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Dugard MN, Kuiper JH, Parker J, Roberts S, Robinson E, Harrison P, Richardson JB. Development of a Tool to Predict Outcome of Autologous Chondrocyte Implantation. Cartilage 2017; 8:119-130. [PMID: 28345413 PMCID: PMC5358825 DOI: 10.1177/1947603516650002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objective The study had 2 objectives: first, to evaluate the success of autologous chondrocyte implantation (ACI) in terms of incidence of surgical re-intervention, including arthroplasty, and investigate predictors of successful treatment outcome. The second objective was to derive a tool predicting a patient's arthroplasty risk following ACI. Design In this Level II, prognostic study, 170 ACI-treated patients (110 males [aged 36.8 ± 9.4 years]; 60 females [aged 38.1 ± 10.2 years]) completed a questionnaire about further surgery on their knee treated with ACI 10.9 ± 3.5 years previously. Factors commonly assessed preoperatively (age, gender, defect location and number, previous surgery at this site, and the preoperative Lysholm score) were used as independent factors in regression analyses. Results At final follow-up (maximum of 19 years post-ACI), 40 patients (23.5%) had undergone surgical re-intervention following ACI. Twenty-six patients (15.3%) underwent arthroplasty, more commonly females (25%) than males (10%; P = 0.001). Cox regression analyses identified 4 factors associated with re-intervention: age at ACI, multiple operations before ACI, patellar defects, and lower pretreatment Lysholm scores (Nagelkerke's R2 = 0.20). Six predictive items associated with risk of arthroplasty following ACI (Nagelkerke's R2 = 0.34) were used to develop the Oswestry Risk of Knee Arthroplasty index with internal cross-validation. Conclusion In a single-center study, we have identified 6 factors (age, gender, location and number of defects, number of previous operations, and Lysholm score before ACI) that appear to influence the likelihood of ACI patients progressing to arthroplasty. We have used this information to propose a formula or "tool" that could aid treatment decisions and improve patient selection for ACI.
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Affiliation(s)
- M. Naomi Dugard
- Robert Jones & Agnes Hunt Orthopaedic NHS Foundation Trust Hospital, Oswestry, Shropshire, UK,Institute of Science and Technology in Medicine, Keele University, Keele, Staffordshire, UK
| | - Jan Herman Kuiper
- Robert Jones & Agnes Hunt Orthopaedic NHS Foundation Trust Hospital, Oswestry, Shropshire, UK,Institute of Science and Technology in Medicine, Keele University, Keele, Staffordshire, UK
| | - Jane Parker
- Robert Jones & Agnes Hunt Orthopaedic NHS Foundation Trust Hospital, Oswestry, Shropshire, UK,Institute of Science and Technology in Medicine, Keele University, Keele, Staffordshire, UK
| | - Sally Roberts
- Robert Jones & Agnes Hunt Orthopaedic NHS Foundation Trust Hospital, Oswestry, Shropshire, UK,Institute of Science and Technology in Medicine, Keele University, Keele, Staffordshire, UK,Sally Roberts, ARC/TORCH Building, RJAH Orthopaedic Hospital, Oswestry, Shropshire SY10 7AG, UK.
| | - Eric Robinson
- Robert Jones & Agnes Hunt Orthopaedic NHS Foundation Trust Hospital, Oswestry, Shropshire, UK
| | - Paul Harrison
- Robert Jones & Agnes Hunt Orthopaedic NHS Foundation Trust Hospital, Oswestry, Shropshire, UK
| | - James B. Richardson
- Robert Jones & Agnes Hunt Orthopaedic NHS Foundation Trust Hospital, Oswestry, Shropshire, UK,Institute of Science and Technology in Medicine, Keele University, Keele, Staffordshire, UK
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Hamad A, Vachtsevanos L, Cattell A, Ockendon M, Balain B. Minimally invasive spinal surgery for the management of symptomatic spinal metastasis. Br J Neurosurg 2017; 31:526-530. [PMID: 28264589 DOI: 10.1080/02688697.2017.1297374] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Symptomatic metastatic spinal disease is on the increase. Minimally invasive spinal surgery has been associated with a lower complication profile when compared to traditional open methods; however there is paucity of literature evaluating the place of percutaneous pedicle screw fixation (PPSF) in the management of spinal metastases. The purpose of the study is to assess the efficacy of Minimally Invasive Spine Surgery (MISS) using PPSF with or without mini-decompression in the management of symptomatic spinal metastases. MATERIAL AND METHODS This is a single institution prospective study of 51 consecutive patients with metastatic spinal disease treated with PPSF. Patients presenting with pathological compression fractures and mechanical instability had PPSF, and those with radiological and/or clinical metastatic spinal cord compression (MSCC) underwent an additional mini-decompression. Data collected included patient demographics, Karnofsky's performance status (KPS), pain scores and neurology. Other data included number and location of involved levels, number of instrumented levels, blood loss, accuracy of screw placement and complications. RESULTS Of the 51 patients, 49 could be successfully treated with MISS (26 females and 23 males). 26 patients (55%) required a mini-decompression. 27 patients (55%) had improvement in KPS by at least 10 points (p < 0.0005). Only 2 patients (4%) had a worsening of KPS, due to other coexisting problems. Six of the 13 patients improved their neurology by one Frankel grade following surgery and 95% reported improvement in pain. Mean blood loss was 92mls for the fixation only group and 222mls for those requiring mini-decompression, with no other differences between these two surgical groups. Screw positioning was excellent in 91%, with 98% having uncompromised bony hold. Only two patients required revision surgery for aseptic loosening. CONCLUSION MISS using PPSF is a safe and reproducible technique that maintains or improves functional outcome in the vast majority of patients presenting with spinal metastases.
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Affiliation(s)
- Abdulkader Hamad
- a Centre for Spinal Studies, Robert Jones Agnes Hunt Orthopaedic Hospital , Oswestry , UK
| | - Leonidas Vachtsevanos
- a Centre for Spinal Studies, Robert Jones Agnes Hunt Orthopaedic Hospital , Oswestry , UK
| | - Andrew Cattell
- a Centre for Spinal Studies, Robert Jones Agnes Hunt Orthopaedic Hospital , Oswestry , UK
| | - Matthew Ockendon
- a Centre for Spinal Studies, Robert Jones Agnes Hunt Orthopaedic Hospital , Oswestry , UK
| | - Birender Balain
- a Centre for Spinal Studies, Robert Jones Agnes Hunt Orthopaedic Hospital , Oswestry , UK
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Zaw AS, Kantharajanna SB, Maharajan K, Tan B, Vellayappan B, Kumar N. Perioperative blood transfusion: does it influence survival and cancer progression in metastatic spine tumor surgery? Transfusion 2016; 57:440-450. [PMID: 27878812 DOI: 10.1111/trf.13912] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 08/21/2016] [Accepted: 09/22/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite advances in surgical techniques for spinal metastases, there is often substantial blood loss, resulting in patients requiring blood transfusion during the perioperative period. Allogeneic blood transfusion (ABT) has been the main replenishment method for lost blood. However, the impact of ABT on cancer-related outcomes has been controversial in various studies. We aimed to evaluate the influence of perioperative ABT on disease progression and survival in patients undergoing metastatic spinal tumor surgery (MSTS). STUDY DESIGN AND METHODS We conducted a retrospective study that included 247 patients who underwent MSTS at a single tertiary institution between 2005 and 2014. The impact of using perioperative ABT (either exposure to or quantities of transfusion) on disease progression and survival was assessed using Cox regression analyses while adjusting for potential confounding variables. RESULTS Of 247 patients, 133 (54%) received ABT. The overall median number of blood units transfused was 2 (range, 0-10 units). Neither blood transfusion exposure nor quantities of transfusion were associated with overall survival (hazard ratio [HR], 1.15 [p = 0.35] and 1.10 [p = 0.11], respectively) and progression-free survival (HR, 0.87 [p = 0.18] and 0.98 [p = 0.11], respectively). The factors that influenced overall survival were primary tumor type and preoperative Eastern Cooperative Oncology Group performance status, whereas primary tumor type was the only factor that had an impact on progression-free survival. CONCLUSIONS This is the first study providing evidence that disease progression and survival in patients who undergo MSTS are less likely to be influenced by perioperative ABT. The worst oncologic outcomes are more likely to be caused by the clinical circumstances necessitating blood transfusion, but not transfusion itself. However, because ABT can have a propensity toward developing postoperative infections, including surgical site infection, the use of patient blood management interventions would be worthwhile rather than relying solely on ABTs for these patients, if and whenever possible.
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Affiliation(s)
- Aye Sandar Zaw
- Department of Orthopaedic Surgery, National University Hospital
| | | | | | - Barry Tan
- Department of Orthopaedic Surgery, National University Hospital
| | | | - Naresh Kumar
- Department of Orthopaedic Surgery, National University Hospital
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Abi Lahoud G, Abi Jaoude S. [Role of surgery in the management of vertebral metastases. General revue]. Cancer Radiother 2016; 20:484-92. [PMID: 27614512 DOI: 10.1016/j.canrad.2016.07.086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 07/12/2016] [Accepted: 07/21/2016] [Indexed: 10/21/2022]
Abstract
The spine is the most common site of skeletal metastases. Treatment decisions for patients with spinal metastases can be challenging and greatly depend on survival prognosis. Surgery remains a valuable weapon in the therapeutic arsenal. A review of the literature describing the role of surgery, the various surgical approaches and the prognostic scores available for the management of spinal metastases was performed and summarized. Surgery for spinal metastases has 3 main objectives: management of pain, achievement of mechanical stability and preservation or restoration of neurological function. A variety of surgical approaches are available and depend on location of tumor, presence of instability, neurological status, oncologic prognosis, general performance status and subsequent treatment measures. The goal of any therapeutic course for a spinal metastasis is the best oncologic and functional result with the least aggressive treatment. Novelty surgical and adjunctive measures allow a multidisciplinary approach to the metastatic spine.
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Affiliation(s)
- G Abi Lahoud
- Unité de chirurgie de la colonne vertébrale et de la moelle épinière, service de neurochirurgie, centre hospitalier Sainte-Anne, 1, rue Cabanis, 75014 Paris, France.
| | - S Abi Jaoude
- Unité de chirurgie de la colonne vertébrale et de la moelle épinière, service de neurochirurgie, centre hospitalier Sainte-Anne, 1, rue Cabanis, 75014 Paris, France
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Choi D, Fox Z, Albert T, Arts M, Balabaud L, Bunger C, Buchowski JM, Coppes MH, Depreitere B, Fehlings MG, Harrop J, Kawahara N, Martin-Benlloch JA, Massicotte EM, Mazel C, Oner FC, Peul W, Quraishi N, Tokuhashi Y, Tomita K, Verlaan JJ, Wang M, Crockard HA. Prediction of Quality of Life and Survival After Surgery for Symptomatic Spinal Metastases: A Multicenter Cohort Study to Determine Suitability for Surgical Treatment. Neurosurgery 2016. [PMID: 26204361 DOI: 10.1227/neu.0000000000000907] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Surgery for symptomatic spinal metastases aims to improve quality of life, pain, function, and stability. Complications in the postoperative period are not uncommon; therefore, it is important to select appropriate patients who are likely to benefit the greatest from surgery. Previous studies have focused on predicting survival rather than quality of life after surgery. OBJECTIVE To determine preoperative patient characteristics that predict postoperative quality of life and survival in patients who undergo surgery for spinal metastases. METHODS In a prospective cohort study of 922 patients with spinal metastases who underwent surgery, we performed preoperative and postoperative assessment of EuroQol EQ-5D quality of life, visual analog score for pain, Karnofsky physical functioning score, complication rates, and survival. RESULTS The primary tumor type, number of spinal metastases, and presence of visceral metastases were independent predictors of survival. Predictors of quality of life after surgery included preoperative EQ-5D (P = .002), Frankel score (P < .001), and Karnofsky Performance Status (P < .001). CONCLUSION Data from the largest prospective surgical series of patients with symptomatic spinal metastases revealed that tumor type, the number of spinal metastases, and the presence of visceral metastases are the most useful predictors of survival and that quality of life is best predicted by preoperative Karnofsky, Frankel, and EQ-5D scores. The Karnofsky score predicts quality of life and survival and is easy to determine at the bedside, unlike the EQ-5D index. Karnofsky score, tumor type, and spinal and visceral metastases should be considered the 4 most important prognostic variables that influence patient management.
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Affiliation(s)
- David Choi
- *Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, University College London, London, United Kingdom; ‡Departments of Neurosurgery and Orthopedic Surgery, Thomas Jefferson University and Hospitals, Philadelphia, Pennsylvania; §Department of Neurosurgery, Medical Center Haaglanden, Haaglanden, the Netherlands; ¶Department of Orthopedic Surgery, L'Institut Mutualiste Montsouris, Paris, France; ‖Department of Orthopedic Surgery, University Hospital of Aarhus, Aarhus, Denmark; #Departments of Orthopedic and Neurological Surgery, Washington University, St. Louis, Missouri; **Department of Neurosurgery, Groningen, the Netherlands; ‡‡Division of Neurosurgery, University Hospital Leuven, Leuven, Belgium; §§Division of Neurosurgery and Spinal Program, University of Toronto and Toronto Western Hospital, Toronto, Ontario, Canada; ¶¶Department of Orthopedic Surgery, Kanazawa Medical University Hospital, Kanazawa, Japan; ‖‖Spinal Unit, Hospital Universitario Dr Peset, Valencia, Spain; ##Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands; ***Department of Neurosurgery, Leiden University Medical Centre, Leiden, the Netherlands; ‡‡‡Centre for Spine Studies and Surgery, Queens Medical Centre, Nottingham, United Kingdom; §§§Department of Orthopaedic Surgery, Nihon University School of Medicine, Japan; ¶¶¶Department of Orthopedic Surgery, Kanazawa University, Kanazawa, Japan; ‖‖‖Department of Neurosurgery, Jackson Memorial Hospital, University of Miami, Miami, Florida
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Evaluation of Scoring Systems and Prognostic Factors in Patients With Spinal Metastases From Lung Cancer. Spine (Phila Pa 1976) 2016; 41:638-44. [PMID: 27018903 DOI: 10.1097/brs.0000000000001279] [Citation(s) in RCA: 21] [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 180 patients with lung cancer spinal metastases, wherein prognostic score-predicted survival was compared with actual survival. OBJECTIVE To evaluate and compare the accuracy of prognostic scoring systems in lung cancer spinal metastases. SUMMARY OF BACKGROUND DATA The modified Tokuhashi, Tomita, modified Bauer, and Oswestry scores are currently used to guide decisions regarding operative treatment of patients with spinal metastases. The best system for predicting survival in patients with lung cancer spinal metastases remains undetermined. The high incidence of spinal metastases from lung cancer and improved survival of patients treated with systemic therapy warrants evaluation of these scoring systems in this particular context. METHODS Patients with lung cancer spinal metastases treated at our institution between May 2001 and August 2012 were studied. Fifty-one patients were treated surgically. The primary outcome measure was survival from the time of diagnosis. Scoring-predicted survival was compared with actual survival. Potential prognostic factors were investigated using Cox regression analyses. Predictive values of each scoring system for 3- and 6-month survival were measured via receiver operating characteristic (ROC) curves. RESULTS Histological subtype (P = 0.015), sex (P = 0.001), Karnofsky performance scale (P = 0.001), extent of neurological palsy (P = 0.002), and visceral metastases (P = 0.037) are significant predictors of survival. Besides the Oswestry spinal risk index, no significant differences were found between different prognostic subgroups within the individual scoring systems. Although the modified Bauer score was most accurate, all four scoring systems had areas under the ROC curve 0.5 or less. CONCLUSION Although better prognostic scores correlated with longer survival, all four scoring systems are inaccurate in prognosticating patients with lung cancer spinal metastases. Specific lung cancer histology appears prognostic and should be considered, especially given the increased survival of patients receiving new targeted therapies appropriate to their disease. LEVEL OF EVIDENCE 3.
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