New therapeutics in spine metastases

Spinal metastases of bronchopulmonary cancer: Role of spinal surgery and value of prognostic scores (Modified Tokuhashi and Tomita)

INTRODUCTION

Bone metastasis is frequent in bronchopulmonary cancer. We report a series of 52 patients, and analyze indications and the efficacy of surgery.

MATERIALS AND METHODS

We retrospectively studied the records of 52 patients operated on for spinal metastases of bronchopulmonary cancer over a 6-year period from January 2009 to December 2014 in the neurosurgery department of the North Hospital of Marseille, France.

RESULTS

Mean age was 63.6 years; with a sex ratio of 3:1 (M:F). Spinal pain associated with vertebral fracture and spinal cord compression was the most frequent clinical presentation (59.6%). SINS score was ≥7 in 78.9% of cases. Karnofski Performance Status was average in 67.4% of cases. Predicted survival beyond 12 months was zero according to the modified Tokuhashi score. The surgical indication was essentially palliative. Evolution showed regression of pain in 84.6% of cases, and stabilization and improvement in motor deficit in 80.6%. Median postoperative survival was 16 months.

CONCLUSION

Our results highlight the interest of surgery for pain relief, spinal stabilization and improvement in neurological function in patients with spinal metastases of bronchopulmonary cancer, and the unreliability of predictive survival scores.

Prediction of early vascular cement leakage following percutaneous vertebroplasty in spine metastases: the Peking University First Hospital Score (PUFHS)

BACKGROUND

Cement leakage into venous blood posed significant challenge to surgeons. The aim of the study was to create a Peking University First Hospital Score (PUFHS) which could evaluate the probability of vascular cement leakage among spine metastases patients following percutaneous vertebroplasty.

METHODS

The study retrospectively enrolled 272 spine metastases patients treated with percutaneous vertebroplasty. We randomly extracted all enrolled patients as the training or validation group and baseline characteristic comparison was assessed between the two groups. Creation of the PUFHS was performed in the training group and validation of the PUFHS was performed in the validation group.

RESULTS

Of all the 272 patients, the total number of included vertebrae was 632 and the median treated levels were 2 per patient. Vascular cement leakage occurred in 26.47% (72/272) of patients. The baseline characteristics were comparable between the two groups (P > 0.05). Three risk predictors (primary cancer types, number of treated vertebrae levels, and vertebrae collapse) were included in the PUFHS. The area under the receiver operating characteristic curve (AUROC) of the PUFHS was 0.71 in the training group and 0.69 in the validation group. The corresponding correct classification rates were 73.0 and 70.1%, respectively. The calibration slope was 0.78 (95% confidence interval[CI]: 0.45-1.10) in the training group and 1.10 (95% CI: 0.73-1.46) in the validation group. The corresponding intercepts were 0.06 (95% CI: - 0.04-0.17) and - 0.0079 (95% CI: - 0.11-0.092), respectively.

CONCLUSIONS

Vascular cement leakage is common among spine metastases after percutaneous vertebroplasty. The PUFHS can calculate the probability of vascular cement leakage, which can be a useful tool to inform surgeons about vascular cement leakage risk in advance.

Innovative Spine Implants for Improved Augmentation and Stability in Neoplastic Vertebral Compression Fracture

Background and objectives: Tumor-related vertebral compression fractures often result in severe back pain as well as progressive neurologic impairment and additional morbidities. The fixation of these fractures is essential to obtain good pain relief and to improve the patients’ quality of life. Thus far, several spine implants have been developed and studied. The aims of this review were to describe the implants and the techniques proposed to treat cancer-related vertebral compression fractures and to compile their safety and efficacy results. Materials and Methods: A systematic MEDLINE/PubMed literature search was performed, time period included articles published between January 2000 and March 2019. Original articles were selected based on their clinical relevance. Results: Four studies of interest and other cited references were analyzed. These studies reported significant pain and function improvement as well as kyphotic angle and vertebral height restoration and maintain for every implant and technique investigated. Conclusions: Although good clinical performance is reported on these devices, the small numbers of studies and patients investigated draw the need for further larger evaluation before drawing a definitive treatment decision tree to guide physicians managing patients presenting with neoplastic vertebral compression fracture.

Metastatic epidural spinal cord compression

INTRODUCTION

Metastatic epidural spinal cord compression (MESSC) is a frequent event in patients affected by solid tumor metastases. Current available approaches for MESCC include corticosteroids, radiotherapy and surgery. In the last few years, surgery has evolved from decompression by laminectomy alone, with the introduction of instrumentation systems by metalware (screws and hooks), and this has been associated to an improvement of clinical results compared to radiotherapy alone. Areas covered: In this narrative review, we outline the phases of management of cancer patients affected by MESSC, and discuss the timing of treatments, their impact on the Quality of life (QoL), and the relative benefits and harms of surgery and radiotherapy. Expert commentary: Despite the fact that clinical and surgical trials will be required to determine the most appropriate surgical technique and timing of surgery, we do expect a newer and more important role for radiotherapy in the management of MESCC patients in the next future. In particular, the implementation of radiotactic stereosurgery as adjuvant to decompressive surgery is expected to increase in the next few years, above all in those patients that can be candidate to the so called separation surgery.

Stereotactic radiosurgery for spinal metastases with or without separation surgery

OBJECT

In patients with significant epidural spinal cord compression, initial surgical decompression and stabilization of spinal metastases, as opposed to radical oncological resection, provides a margin around the spinal cord that facilitates subsequent treatment with high-dose adjuvant stereotactic radiosurgery (SRS). If a safe margin exists between tumor and spinal cord on initial imaging, then high-dose SRS may be used as the primary therapy, eliminating the need for surgery. Selecting the appropriate approach has shown greater efficacy of tumor control, neurological outcome, and duration of response when compared with external beam radiotherapy, regardless of tumor histology. This study evaluates the efficacy of this treatment approach in a series of 57 consecutive patients.

METHODS

Patients treated for spinal metastases between 2007 and 2011 using the Varian Trilogy Linear Accelerator were identified retrospectively. Each received SRS, with or without initial surgical decompression and instrumentation. Medical records were reviewed to assess neurological outcome and surgical or radiation-induced complications. Magnetic resonance images were obtained for each patient at 3-month intervals posttreatment, and radiographic response was assessed as stability/regression or progression. End points were neurological outcome and local radiographic disease control at death or latest follow-up.

RESULTS

Fifty-seven patients with 69 lesions were treated with SRS for spinal metastases. Forty-eight cases (70%) were treated with SRS alone, and 21 (30%) were treated with surgery prior to SRS. A single fraction was delivered in 38 cases (55%), while a hypofractionated scheme was used in 31 (45%). The most common histological entities were renal cell, breast, and lung carcinomas. Radiographically, local disease was unchanged or regressed in 63 of 69 tumors (91.3%). Frankel score improved or remained stable in 68 of 69 cases (98.6%).

CONCLUSIONS

SRS, alone or as an adjunct following surgical decompression, provides durable local radiographic disease control while preserving or improving neurological function. This less-invasive alternative to radical spinal oncological resection appears to be effective regardless of tumor histology without sacrificing durability of radiographic or clinical response.

The Spine Instability Neoplastic Score: an independent reliability and reproducibility analysis

BACKGROUND

Metastatic vertebral instability has not yet been clearly defined in the literature; there still exists a paucity of reliable criteria to assess the risk of vertebral collapse.

PURPOSE

We performed an independent interobserver and intraobserver agreement evaluation of the Spine Instability Neoplastic Score (SINS) and correlated the score with selected clinical cases and the treatment they received.

STUDY DESIGN

Independent reliability study for the newly created SINS.

PATIENT SAMPLE

Thirty patients who underwent either radiotherapy alone or surgery followed by radiotherapy were randomly selected from the orthopedic surgery and radiotherapy department's databases.

OUTCOME MEASURES

Patients were rated and classified for spinal stability using SINS. Intraclass correlation coefficient (ICC) and Fleiss's kappa measures were occupied for reliability analysis.

METHODS

Patients who underwent either radiotherapy alone or surgery followed by radiotherapy were randomly selected and classified for spinal stability using the SINS by orthopedic surgeons and nonorthopedic oncology specialists. ICC and Fleiss's kappa were calculated for inter- and intraobserver agreement. A comparative analysis of SINS and the actual management was also conducted.

RESULTS

Interobserver ICC reliability for the SINS was 0.79; κ values for location, pain, bone quality, alignment, vertebral body collapse, and posterolateral involvement were 0.81, 0.58, 0.21, 0.45, 0.42, and 0.29 respectively. Intraobserver ICC for the SINS scores was 0.96; ICC values for the same components were 0.98, 0.98, 0.87, 0.88, 0.92, and 0.86, respectively. Potentially unstable lesions (SINS score≥7) were operated on in 62.5%.

CONCLUSIONS

SINS seem to be a reproducible tool that could be used equally by multiple specialists to estimate metastatic vertebral stability; however, prospective clinical validation is still pending.

Diagnosis and management of metastatic spine disease. A review

With continued growth of the elderly population and improvements in cancer therapies, the number of patients with symptomatic spinal metastases is likely to increase, and this is a condition that commonly leads to debilitating neurological dysfunction and pain. Advancements in surgical techniques of resection and spinal reconstruction, improvements in clinical outcomes following various treatment modalities, generally increased overall survival in patients with metastatic spine disease, and a recent randomized trial by Patchell and colleagues demonstrating the superiority of a combined surgical/radiotherapeutic approach over a radiotherapy-only strategy have led many to suggest increasingly aggressive interventions for patients with such lesions. Optimal management of spinal metastases encompasses numerous medical specialties, including neurosurgery, orthopedic surgery, medical and radiation oncology, radiology, and rehabilitation medicine. In this review, the clinical presentation, diagnosis, and management of spinal metastatic disease are discussed. Ultimately, the goal of treatment in patients with spinal metastases remains palliative, and clinical judgment is required to select the appropriate patients for surgical intervention.

Radiosurgery in the treatment of spinal metastases: tumor control, survival, and quality of life after helical tomotherapy

OBJECTIVE

The effectiveness and limitations of spinal radiosurgery using a helical TomoTherapy system for the treatment of spinal metastases are reviewed in this article.

METHODS

This is a retrospective review of patients who underwent stereotactic radiosurgery for spinal metastases between July 2004 and December 2007. Radiographic follow-up consisted of magnetic resonance imaging to assess tumor growth control as well as pre- and posttreatment x-rays, which were used to measure changes in segmental angulation and deformity. Clinical performance was assessed using the Karnofsky Performance Scale, Oswestry Disability Index, and visual analog scale.

RESULTS

Forty patients were treated for 110 metastatic tumors (range, 1-6 tumors per patient). The mean age at the time of radiosurgical treatment was 67 years (age range, 35-81 years). Twenty-three patients (57.5%) had undergone previous surgical resection. Pain was the most common presenting symptom, seen in 32 patients (80%). The mean Oswestry Disability Index score at presentation was 43 (range, 20-90), and the mean visual analog scale score was 6.2 (range, 0-10). The mean radiosurgical dose to the tumor was 17.3 Gy (range, 10-24 Gy). At a mean follow-up duration of 12.7 months (range, 4-32 months), decreased or stable tumor volume was seen in 90 (82%) of the tumors treated. There was improvement in pain in 34 patients (85%). The mean postradiosurgical Oswestry Disability Index score was 25 (range, 10-90), whereas the postradiosurgical visual analog scale score was 3.2 (range, 0-9). Progression of kyphosis was the most common radiographic sequela, experienced by 73% of patients alive at 12 months, with a mean change in angulation of 7.3 +/- 4.5 degrees.

CONCLUSION

Radiosurgery is effective as either primary or adjunctive treatment of metastatic tumors of the spine.

Conventionally-fractionated image-guided intensity modulated radiotherapy (IG-IMRT): a safe and effective treatment for cancer spinal metastasis

BACKGROUND

Treatments for cancer spinal metastasis were always palliative. This study was conducted to investigate the safety and effectiveness of IG-IMRT for these patients.

METHODS

10 metastatic lesions were treated with conventionally-fractionated IG-IMRT. Daily kilovoltage cone-beam computed tomography (kV-CBCT) scan was applied to ensure accurate positioning. Plans were evaluated by the dose-volume histogram (DVH) analysis.

RESULTS

Before set-up correction, the positioning errors in the left-right (LR), superior-inferior (SI) and anterior-posterior (AP) axes were 0.3 +/- 3.2, 0.4 +/- 4.5 and -0.2 +/- 3.9 mm, respectively. After repositioning, those errors were 0.1 +/- 0.7, 0 +/- 0.8 and 0 +/- 0.7 mm, respectively. The systematic/random uncertainties ranged 1.4-2.3/3.0-4.1 before and 0.1-0.2/0.7-0.8 mm after online set-up correction. In the original IMRT plans, the average dose of the planning target volume (PTV) was 61.9 Gy, with the spinal cord dose less than 49 Gy. Compared to the simulated PTVs based on the pre-correction CBCT, the average volume reduction of PTVs was 42.3% after online correction. Also, organ at risk (OAR) all benefited from CBCT-based set-up correction and had significant dose reduction with IGRT technique. Clinically, most patients had prompt pain relief within one month of treatment. There was no radiation-induced toxicity detected clinically during a median follow-up of 15.6 months.

CONCLUSION

IG-IMRT provides a new approach to treat cancer spinal metastasis. The precise positioning ensures the implementation of optimal IMRT plan, satisfying both the dose escalation of tumor targets and the radiation tolerance of spinal cord. It might benefit the cancer patient with spinal metastasis.

Barriers to rehabilitation of the neurosurgical spine cancer patient

The treatment of metastatic spine tumors has evolved significantly over the past 20 years due largely to improvements in magnetic resonance imaging; decompressive surgical techniques, spinal instrumentation, and high-dose conformal radiation. These advances have improved our ability to provide meaningful palliation for patients who often have significant medical and cancer-related issues. Despite technical advances that have improved our ability to maintain neurologic function, stabilize the spine, and prevent local tumor recurrences, significant barriers to rehabilitation remain. This article reviews these primary barriers to rehabilitation of the cancer patient following spine surgery and emphasizes the importance of diagnostic accuracy and a comprehensive team approach to the treatment of pain and other disorders in this population.

Surgical approach to epidural spinal cord compression

NOMS provides a framework to make decisions regarding surgery or radiation in the face of changing technology. NOMS reflects the most important decision points including neurologic, oncologic, mechanical stability, and systemic disease. Currently, patients who have high-grade epidural spinal cord compression (N) from radioresistant disease (O) or demonstrate mechanical instability (M) are offered surgery if they can tolerate it from a systemic (S) standpoint. Patients with radiosensitive tumors (O) are offered external beam radiation regardless of the degree of spinal cord compression (N). Patients with radioresistant tumors (O) who do not have significant spinal cord compression (N) are now offered IGIMRT as the best chance of controlling local tumor and avoiding an operation.

Metastatic Epidural Spinal Cord Compression: Update on Management

Until recently, patients with metastatic epidural spinal cord compression (MESCC) were routinely treated with corticosteroids and radiotherapy (RT). However, major advances in imaging, recognition of new prognostic factors, and new techniques in RT and surgery have led to a number of management choices that need to be considered when treating a patient with MESCC. In our view, the management should be individualized taking into account many variables. We present here some of the advances we believe are among the most important. A historical background to the modern management of this condition is first presented.