Total en bloc spondylectomy for spinal metastases in thyroid carcinoma

En bloc vertebrectomy: A radical technique for spinal metastases but rarely used

INTRODUCTION AND IMPORTANCE

Total vertebrectomy En bloc by posterior approach is proposed for primary or secondary single-site malignant tumors of the spine to reduce local recurrence and increase patient survival. This type of surgery is gaining increasing recognition. However, it requires a high level of technical skill and knowledge of the anatomy, physiology and biomechanics of the spine.

CASE PRESENTATION

We present here a case of a patient with a single thoracic metastasis with neurological deficit treated by total vertebrectomy via the posterior approach, using a cage and pedicle screws in situ.

DISCUSSION

This surgery is technically demanding, and patient selection therefore requires careful preoperative evaluation.

CONCLUSION

The reproducibility of the En bloc vertebrectomy method documented in the literature is demonstrated and supported by our case.

Stereotactic Radiosurgery for Patients with Spinal Metastases from Thyroid Cancer: A 20-Year Experience

OBJECTIVE

Primary thyroid cancer metastasizing to the spine portends poor survival and low quality of life. Current management strategies continue to evolve. This single-institution retrospective study analyzes outcomes after spinal stereotactic radiosurgery for patients with spinal metastases from thyroid cancer.

METHODS

Nineteen patients (median age: 64.5 years) were treated with stereotactic radiosurgery (SRS) for spinal primary thyroid metastases (40 metastases, 47 vertebral levels) between 2003 and 2023. Nineteen (47.5%) lesions had epidural involvement and 20 (50%) lesions were classified as potentially unstable or unstable via the Spinal Instability Neoplastic Score. The median tumor volume per lesion was 33 cc (range: 1.5-153). The median single fraction prescription dose was 20 Gy (range: 12-23.5).

RESULTS

The median follow-up period was 15 months (range: 2-40). Five (12.8%) lesions locally progressed at a median of 9 months (range: 4-26) after SRS. The 1-, 2-, and 3-year local tumor control rates per lesion were 90.4%, 83.5%, and 75.9%, respectively. On univariate analysis, age at SRS >70 years (P = 0.05, hazard ratio: 6.86, 95% confidence interval: 1.01-46.7) was significantly correlated with lower rates of local tumor control. The median overall survival was 35 months (range: 2-141). The 1-, 2-, and 3-year overall survival rates were 73.7%, 50.4%, and 43.2%, respectively. For 33 lesions initially associated with pain, patients reported pain improvement (22 lesions, 66.7%), stability (10 lesions, 30.3%), and worsening (1 lesion, 3.0%) after SRS. One patient developed dysphagia 4 months after SRS treatment.

CONCLUSIONS

SRS can be utilized as an effective and safe primary and adjuvant treatment option for primary thyroid metastases to the spine.

Therapeutic approaches in patients with bone metastasis due to endometrial carcinoma - A systematic review

Background

Bone metastases (BM) are uncommon in endometrial carcinoma (EC), without information on the optimal oncologic management of patients with BM in EC. Here, we systematically review clinical characteristics, treatment approaches and prognosis in patients with BM in EC.

Methods

We conducted a systematic literature search until 27th March 2022 on PubMed, MEDLINE, Embase and clinicaltrials.gov. Outcomes included treatment frequency and survival after BM with comparators being treatment approaches (local cytoreductive bone surgery, systemic therapy, and local radiotherapy). Risk of bias was assessed using the NIH Quality Assessment Tool and Navigation Guide methodology.

Results

We retrieved 1096 records of which 112 retrospective studies (12 cohort studies, 12/12 fair quality; 100 case studies, 100/100 low quality) with a total of 1566 patients were included. The majority had a primary diagnosis of FIGO stage IV, grade 3 endometrioid EC. Singular BM were present in a median of 39.2%, multiple BM in 60.8% and synchronous additional distant metastases in 48.1% of patients respectively. In patients with secondary BM median time to bone recurrence was 14 months. Median survival after BM was 12 months. Local cytoreductive bone surgery was assessed in 7/13 cohorts and performed in a median of 15.8% (interquartile range [IQR] 10.3-43.0) of patients. Chemotherapy was assessed in 11/13 cohorts and administered in a median of 55.5% (IQR 41.0-63.9), hormonal therapy (7/13 cohorts) in 24.7% (IQR 16.3-36.0), and osteooncologic therapy (4/13 cohorts) in 2.7% (IQR 0.0-7.5) of patients respectively. Local radiotherapy was assessed in 9/13 cohorts and performed in a median of 66.7% (IQR 55.6-70.0) of patients. Survival benefits were seen in 2/3 cohorts after local cytoreductive bone surgery, and in 2/7 cohorts after chemotherapy without survival benefits in the remaining cohorts and investigated therapies. Limitations include the lack of controlled intervention studies, the heterogeneity and retrospective nature of the investigated populations.

Conclusions

This systematic review shows heterogenous therapeutic approaches in clinical practice without clear evidence for optimal oncologic management for patients with BM in EC.

Surgery for metastatic spinal differentiated thyroid cancer: feasibility, outcome, and prognostic factors

Study design

A retrospective cohort study.

Objectives

This study aims to report the surgical outcome of metastatic spinal differentiated thyroid cancer (MSDTC) and analyze the factors affecting the prognosis.

Methods

Thirty-five patients were recruited in our single institution who underwent spinal surgery and adjuvant therapies from 2009 to 2019. Two surgical procedures, total en-bloc spondylectomy and debulking surgery, were undertaken. Their clinical data, postoperative events, and survival data were collected and analyzed. Survival time and associated factors were further analyzed.

Results

The cohort had a median survival time of 60 months. The mean visual analog scale scores and the Karnofsky performance score improved postoperatively (p < 0.05). The patients' Frankel grade was elevated for cases with preoperative neurological deficits (p < 0.05). In 31 patients who underwent debulking surgery, 41.9% (n = 13) had local recurrences, and radiotherapy reduced the risk of local relapse (p < 0.05). Preoperative and postoperative Frankel grades and radioactive iodine (RAI) therapy were associated with the patients' survival in the univariate analysis (p < 0.05). Furthermore, a multivariate regression analysis showed the postoperative Frankel grade as an independent prognostic factor.

Conclusion

Pain, quality of life, and neurological status of patients can be effectively improved after surgery. Radiotherapy can reduce the risk of local recurrences, whereas RAI therapy has a limited effect on local and extraspinal tumor control. Neurological status was independently associated with the patients' survival.

Metastasectomy of spinal lesions from thyroid carcinomas

Patients with differentiated thyroid carcinomas (DTCs) have a favourable long-term survival. Spinal metastases (SMs) cause a decline in performance status (PS), directly affecting mortality and indirectly preventing the use of systemic therapies. Metastasectomy is indicated, if feasible, as it yields the best local tumour control. Our study aimed to examine the long-term clinical outcomes of metastasectomy for SMs of thyroid carcinomas. We collected data on 22 patients with DTC (16 follicular and six papillary carcinomas) and one patient with medullary carcinoma who underwent complete surgical resection of SMs at our institution between July 1992 and July 2017, with a minimum postoperative follow-up of five years. The cancer-specific survival (CSS) from the first spinal metastasectomy to death or the last follow-up was determined using Kaplan-Meier analysis. Potential factors associated with survival were evaluated using the log-rank test. We analyzed the clinical parameters and outcome data, including pre- and postoperative disability (Eastern Cooperative Oncology Group PS 3), lung and non-spinal bone metastases, and history of radioiodine and kinase inhibitor therapies. Lung and other bone metastases at the time of surgery were observed in ten and eight patients, respectively. Three patients experienced local tumour recurrences at the operated site. The five- and ten-year CSS rates in the 22 patients with DTC were 77% and 52%, respectively. Pre- and postoperative disability and operative site tumour recurrence were identified as risk factors for short postoperative survival. Metastasectomy for resectable SM from DTC yielded favourable results and has the potential to improve survival.

Ten-year trends in the treatment and intervention timing for patients with metastatic spinal tumors: a retrospective observational study

BACKGROUND

Cancer treatment has recently evolved due to the advances in comprehensive therapies, including chemotherapy and radiotherapy. The aspect of cancer-related bone metastasis has undergone a paradigm shift with the transformation of orthopedic interventions for spinal metastasis. We performed this retrospective observational study to investigate the changes in patient status and metastatic spine-tumor treatment over the past decade.

METHODS

We included 186 patients (122 men and 64 women; mean age: 67.6 years) who were referred to our hospital between 2009 and 2018 and were diagnosed and treated for metastatic spinal tumors. We classified the patients into early (81 patients from 2009 to 2013) and late (105 patients from 2014 to 2018) groups. The following components were investigated and compared between the groups: primary tumor, time taken from subjective-symptom onset to hospital visit, primary tumor evaluation during the visit, walking capacity due to lower paralysis during the visit, local treatment details, and post-treatment functional prognosis.

RESULTS

Predominant primary tumors with similar trends in both groups included lung cancer, multiple myeloma, and prostate cancer. The percentage of non-ambulatory patients during the consultation was significantly lower in the late group (28% vs. 16%, P = 0.04). Among non-ambulatory patients at the time of hospital visit, the mean time from the primary doctor consultation to our hospital visit was 2.8 and 2.1 days in the early and late groups, respectively. In both groups, surgical procedures were performed promptly on the non-ambulatory patients; however, postoperative lower function did not improve in approximately half of the patients.

CONCLUSIONS

Our findings demonstrated that in recent years, patients tended to be referred promptly from their previous doctors under a favorable collaboration system. However, the effectiveness of lower paralysis treatment remains limited, and it is important to raise awareness regarding the importance of early consultation among the general public for earlier detection.

A Modified Spinal Reconstruction Method Reduces Instrumentation Failure in Total En Bloc Spondylectomy for Spinal Tumors

Introduction

Long-term spinal stability after total en bloc spondylectomy (TES) is challenging. The aim of this study was to examine whether the new method could reduce the incidence of instrumentation failure (IF).

Methods

We retrospectively compared 116 patients with spinal tumors who underwent TES between 2010 and 2019 and were followed up for >1 year. IF, cage subsidence, and complications were evaluated. Propensity score matching between conventional and new method groups was performed for age, sex, body mass index, preoperative radiotherapy, number of resected vertebrae, number of instrumented vertebrae, tumor level, and follow-up period. There were 25 cases each in the conventional and new method groups. The conventional method used a titanium mesh cage for anterior reconstruction and 5.5-mm-diameter titanium alloy rods for posterior fixation. The new method used a more robust cage for anterior reconstruction, bone grafting was performed around the cage, and 6.0-mm-diameter cobalt chromium rods were used for posterior fixation. We compared the incidence of IF and cage subsidence after TES between the conventional and new method groups.

Results

While 5 out of 25 patients (20.0%) in the conventional method group experienced IF, none from the new method group experienced IF. Three-year implant survival rates were 87.3% in the conventional and 100% in the new method groups. The new method group had a significantly higher implant survival rate (p<0.01). Cage subsidence was observed in 11 of 25 (44/0%) patients in the conventional method and 1 of 25 (4.0%; significantly lower, p<0.05) in the new method group.

Conclusions

The new reconstruction method significantly reduced IF incidence in patients with TES.

Management of Progressive Radioiodine-Refractory Thyroid Carcinoma: Current Perspective

Patients with thyroid cancer (TC) usually have an excellent prognosis; however, 5-10% of them develop an advanced disease. The prognosis of this subgroup is still favourable if the lesions respond to radioactive iodine (RAI) treatment. Nearly two-thirds of advanced TC patients become RAI-refractory (RAI-R), and their management is challenging. A multidisciplinary approach in the context of a tumour board is essential to define a personalized strategy. Systemic therapy is not always the best option. In case of slow neoplastic growth and low tumour burden, active surveillance may represent a valuable choice. Local approaches might be considered if the disease progression is limited to a single or few lesions, also in combination and during systemic therapy. Antiresorptive treatment may be started in presence of bone metastases. In case of rapid and/or symptomatic progression involving multiple lesions and/or organs, systemic therapy has to be considered, in absence of contraindications. The multi-kinase inhibitors (MKIs) lenvatinib and sorafenib are currently available as first-line treatment for advanced progressive RAI-R TC. Among second-line options, cabozantinib has been recently approved in RAI-R TC who progressed during MKIs targeting the vascular endothelial growth factor receptor (VEGFR). In the last few years, next-generation sequencing (NGS) assays have been increasingly employed, permitting identification of the genetic alterations harboured by TC, with a significant impact on patients' management. Novel selective targeted therapies have been introduced for the treatment of RAI-R TC in selected cases: REarranged during Transfection (RET) inhibitors (selpercatinib and pralsetinib) and Tropomyosin Receptor Kinase (TRK) inhibitors (larotrectinib and entrectinib) have recently expanded the panorama of the therapeutic options. Moreover, immune checkpoint inhibitors (ICIs) have shown promising results, and they are still under investigation.

Medium to Long-Term Clinical Outcomes of Spinal Metastasectomy

The prolonged survival of metastatic cancer patients highlights the importance of the local control of spinal metastases, which reduce patient performance status. This retrospective study examined the medium to long-term outcomes of spinal metastasectomy by evaluating 124 patients who underwent metastasectomy for isolated spinal metastases (2006-2018) with a postoperative follow-up for a minimum of 3 years. The findings present information on patient demographics (i.e., performance status, location of non-spinal metastases, and history of systemic therapy) and postoperative outcomes, including perioperative complications, disease progression of non-operated metastases, and additional excisional surgeries. Additionally, postoperative survival, local tumor control in the operated spine, and maintenance of spinal reconstruction without instrumentation failure were determined using Kaplan-Meier analyses. The primary malignancy was kidney and thyroid cancer in 51 and 14 patients, respectively, low-grade sarcoma and lung cancer in 13 patients, breast cancer in 12 patients, and other malignancies in 21 patients. The 3-year and 5-year survival rates were 70% and 60%, respectively. We found that patients with thyroid cancer had the best survival results, with local tumor recurrence and instrumentation failure at 10% and 22%, respectively. These findings suggest that for certain patients with isolated and removable spine metastases, metastasectomy can improve function and survival.

The role of surgery in the treatment of metastatic bone tumor

Surgery for bone metastasis has two primary goals-palliative care to relieve pain, instability and paralysis, and tumor resection for curing the disease. Oncologically en bloc resection, followed by a reconstruction of the bone defect is the treatment of choice in single bone metastasis from renal cell carcinoma or thyroid cancer. Bone metastases may occur in the extremities, pelvis, or spine, and different resection and reconstruction methods depend on the regional anatomy. For instance, multiple options are available for reconstruction of the pelvis, especially for the acetabulum, including anatomical reconstruction using custom-made implants or recycled autologous bone grafting when a long-term prognosis is expected. Recently, for the spine, total en bloc spondylectomy is extensively performed despite the initial limitations of surgical invasiveness, such as blood loss. Principally, palliative surgery aims to maintain lasting bony stability with minimal surgical invasiveness. Intramedullary nails and plate fixation are frequently used in the extremities but the postoperative failure rate is relatively high. Therefore, surgeons should consider the use of long intramedullary nails and long-type stems for endoprosthesis reconstruction along with cement fixation to reduce the failure rate. Although short-term complications, such as dislocation, have been observed with endoprosthesis reconstruction, it is stable in the long-term follow-up. Percutaneous bone cement injection into the spine and pelvis is also effective and less invasive.

Follicular thyroid carcinoma with an iliac wing metastasis - Rare case report at Bugando Medical Centre in Tanzania

Thyroid carcinoma is uncommon in our geographical setting. When it occurs the leading histological type is papillary thyroid carcinoma followed by follicular thyroid carcinoma which are differentiated thyroid carcinomas. Differentiated thyroid carcinomas usually have a good prognosis as compared to undifferentiated thyroid carcinomas. Follicular Thyroid Carcinoma usually presents with a solitary thyroid nodule with or without cervical lymphadenopathy. We present a 57 year old female with history of anterior neck swelling for 5 years and inability to walk using the left lower limb for 2 years. Total thyroidectomy and modified neck dissection was done. Histopathology results revealed follicular thyroid carcinoma. Patient was received radiochemotherapy treatment post-surgery. Follicular thyroid carcinoma may present with a symptomatic distant metastatic bony lesion as presented. It is important for clinicians to be aware this and carry out confirmatory relative investigations.

Current Management of Bone Metastases from Differentiated Thyroid Cancer

Simple Summary

Patients with bone metastases (BMs) from differentiated thyroid carcinoma (DTC) can live longer than those with BMs from other cancers. BMs from DTC create destructive lesions and easily cause intractable pain and neurological symptoms, including paralysis. These symptoms related to BMs affect mortality directly and indirectly by hampering the application of systemic therapies. Therefore, long-term local control of BMs in patients with DTC is desired, especially in patients with single or a small number of metastases. Local treatments for BMs have recently become advanced and sophisticated in surgery, radiotherapy, and percutaneous procedures. These therapies, either alone or in combination with other treatments, can effectively improve, or prevent the deterioration of, the performance status and quality of life of patients with DTC-BM. Among local therapies, complete surgical resection and stereotactic radiosurgery are the mainstay for achieving long-term control of DTC-BM.

Abstract

After the lung, the skeleton is the second most common site of distant metastases in differentiated thyroid carcinoma (DTC). Patients with osteolytic bone metastases (BMs) from thyroid carcinoma often have significantly reduced performance status and quality of life. Recent advancements in cancer therapy have improved overall survival in multiple cancer subtypes, including thyroid cancer. Therefore, long-term local control of thyroid BMs is desired, especially in patients with a single metastasis or oligometastases. Here, we reviewed the current management options for DTC-BMs and especially focused on local treatments for long-term local tumor control from an orthopedic tumor surgeon’s point of view. Metastasectomy and stereotactic radiosurgery can be performed either alone or in combination with radioiodine therapy and kinase inhibitors to cure skeletal lesions in selected patients. Percutaneous procedures have been developed in recent years, and they can also have a curative role in small BMs. Recent advancements in local therapies have the potential to provide not only long-term local tumor control but also a better prognosis.

Spondylectomy in the treatment of neoplastic spinal lesions - A retrospective outcome analysis of 582 patients using a patient-level meta-analysis

This study aims at identifying predictors of postoperative complications, lesion recurrence, and overall survival in patients undergoing en bloc spondylectomy (EBS) for spinal tumors. For this purpose a systematic review of the literature was conducted and patient-level data extracted. Linear-regression models were calculated to predict postoperative complications, lesion recurrence and overall survival based on age, tumor etiology, surgical approach, mode of resection (extra- vs. intralesional), tumor extension, and number of levels treated. A total of 582 patients were identified from the literature: 45% of females, median age 46 years (5-78); most common etiologies were: sarcoma (46%), metastases (31%), chordoma (11%); surgical approach was anterior (2.5%), combined (45%), and posterior (52.4%); 68.5% underwent EBS; average levels resected were 1.6 (1-6); average survival was 2.6 years; Complication rate was 17.7%. The following significant correlations were found: postoperative complications and resection mode (Odds ratio [OR] 1.35) as well as number of levels treated (OR 1.35); tumor recurrence and resection mode (OR 0.78); 5-year survival and age (OR 0.79), tumor grade (OR 0.65), tumor stage at diagnosis (OR 0.79), and resection mode (OR 1.68). EBS was shown to improve survival, decreases recurrence rates but also has a higher complication rate. Interestingly, the complication rate was not influenced by tumor extension or tumor etiology.

Surgical Metastasectomy in the Spine: A Review Article

BACKGROUND

The use of surgical metastasectomy (SM) has increased across cancer types in recent decades despite the increasing efficacy of modern systemic treatment modalities. Symptomatic spinal metastases severely compromise patients' performance status. However, as spinal SM is a complex surgery with potentially significant complications, it is not considered the treatment of choice.

METHODS

We reviewed the articles on SM in several primary cancers with different types of metastatic lesions and extracted the data from relevant articles to provide a comprehensive review including the surgical techniques, indications, reported outcomes, and future prospects of SM in spinal metastases.

RESULTS

Total en bloc spondylectomy (TES) is a method of spinal SM associated with a lower risk of tumor recurrence and complications. Intralesional transpedicular osteotomy using a fine threadwire saw allows prevention of spinal cord and nerve root injuries. Spinal SM is considered suitable for patients with controlled primary disease having no evidence of disseminated extraspinal metastases, a completely resectable solitary lesion in the spine, and adequate cardiopulmonary reserve to tolerate the surgery. Metastatic lesions from kidney and thyroid cancers have been reported as the best candidates for spinal SM. Although data about spinal SM are limited, the reported outcomes are favorable with acceptable local recurrence rates in long-term follow-up.

CONCLUSION

In patients with isolated resectable spinal metastases, complete SM including TES is a useful option as it can improve function and survival. However, appropriate patient selection and surgical feasibility remain the most important aspects of management.

IMPLICATIONS FOR PRACTICE

Surgical metastasectomy for spinal metastases may be a potentially curative treatment option with a low risk of local recurrence and lead to prolonged long-term survival if appropriate patients are selected and if the surgery is carried out by experienced surgeons in high-volume centers.

Surgery for metastatic epidural spinal cord compression in thoracic spine, anterior or posterior approach?

BACKGROUND

The most commonly encountered tumour of the spine is metastasis, and thoracic spine is the most commonly metastatic spine. Controversy exists regarding the optimal surgical approach for this kind of patient. The author conducted a study to assess the differences between anterior thoracotomy and a posterior approach in patients with malignant epidural cord compression in the thoracic spine.

METHODS

Between January 2004 and December 2017, 97 patients with metastatic thoracic lesion were stratified into two groups by approach method to the lesion site: Group A - mean anterior thoracotomy, decompression and fixation; and Group P - represented posterior decompression and fixation. Survival time, neurologic status, each complication by surgery or in hospital, and days in intensive care unit(ICU) were compared.

RESULTS

Twenty-five patients were grouped in Group A, and 72 patients belonged to Group P. Lung cancer was the most common primary cancer in both groups. Operation time (213.0 vs. 199.2 min, p = 0.380) and blood loss (912.5 vs. 834.4 ml, p = 0.571) were not statistically significantly different between the two groups. Six patients in Group A (24%) and 6 in Group P (8.3%) developed complications (p = 0.040). Patients in Group A required more days of care in ICUs (2.36 vs. 0.19 days, p < 0.001). The longer survival was seen in Group P (15.4 vs. 11.2 months) but with no significant difference.

CONCLUSION

A lower surgical complication rate and fewer days of care in ICU were seen in Group P. The authors would prefer a posterior approach for those with thoracic metastatic tumour.

Bone metastases from differentiated thyroid carcinoma: current knowledge and open issues

Bone represents the second most common site of distant metastases in differentiated thyroid cancer (DTC). The clinical course of DTC patients with bone metastases (BM) is quite heterogeneous, but generally associated with low survival rates. Skeletal-related events might be a serious complication of BM, resulting in high morbidity and impaired quality of life. To achieve disease control and symptoms relief, multimodal treatment is generally required: radioiodine therapy, local procedures-including surgery, radiotherapy and percutaneous techniques-and systemic therapies, such as kinase inhibitors and antiresorptive drugs. The management of DTC with BM is challenging: a careful evaluation and a personalized approach are essential to improve patients' outcomes. To date, prospective studies focusing on the main clinical aspects of DTC with BM are scarce; available analyses mainly include cohorts assembled over multiple decades, small samples sizes and data about BM not always separated from those regarding other distant metastases. The aim of this review is to summarize the most recent evidences and the unsolved questions regarding BM in DTC, analyzing several key issues: pathophysiology, prognostic factors, role of anatomic and functional imaging, and clinical management.

Surgical Impacts of Metastatic Non-small Cell Lung Cancer to the Thoracic and Lumbar Spine

BACKGROUND

Surgery for spinal metastasis is rapidly increasing in frequency with procedures ranging from laminectomy to spondylectomy combined with stabilization. This study investigated the effect of various surgical procedures for spinal metastasis of non-small cell lung cancer (NSCLC).

METHODS

A single-center consecutive series of patients who underwent surgery for spinal metastasis of NSCLC were retrospectively reviewed. Patients' characteristics, radiographic parameters, operative data, clinical outcomes, and complications were analyzed. Surgical outcomes were assessed according to pain and performance status before and after surgery. Overall survival (OS) rate was estimated using the Kaplan-Meier method. Multivariate analysis was performed to detect factors independently associated with OS using a Cox proportional hazards model.

RESULTS

Twenty-one patients were treated with laminectomy, 24 with corpectomy, 13 with spondylectomy (piecemeal or total en bloc fashion), and all procedures were combined with stabilization. Back pain and performance status improved significantly after surgical treatment among the three groups. Revision surgery due to tumor progression at the index level or spinal metastasis at another level were four patients (19.0%) in the laminectomy group, six patients (25.0%) in the corpectomy group, and one patient (7.7%) in the spondylectomy group. A Charlson comorbidity index and the number of spinal metastasis negatively affected OS (hazard ratio [HR], 19.613 and 2.244). Postoperative chemotherapy, time to metastasis, spondylectomy, and corpectomy had favorable associations with OS (HR, 0.455, 0.487, 0.619, and 0.715, respectively).

CONCLUSION

Postoperative chemotherapy was the most critical factor in OS of patients with metastatic NSCLC to the spine. An extensive surgical procedure (corpectomy/spondylectomy) with stabilization also could be beneficial for limited patients with spinal metastasis of NSCLC.

Role of laser ablation in multimodal treatment of radioiodine- refractory bone metastases of thyroid cancer: a retrospective study

PURPOSE

To assess the efficacy, safety, and pain benefits of imaging-guided laser ablation (IGLA) in patients with radioiodine-refractory (RR) bone metastases from differentiated thyroid carcinoma (DTC).

PATIENTS AND METHODS

The institutional medical records of patients with bone metastases from DTC treated with laser ablation (LA) were reviewed retrospectively. Local response, complications, and effects on pain relief were investigated.

RESULTS

Six osteolytic lesions in five patients (one male, four females; mean age 65.4 ± 5.1 years, range 58-72) were treated with IGLA. All lesions were osteolytic and all have had previous treatments with high-dose radioiodine therapy followed by external radiotherapy (EBRT). All patients assumed opioid analgesics for severe pain. Overall, the lesions (mean size 5.8 ± 3.2 cm; median 5.0 cm, range 3.0-12.0 cm) underwent nine IGLA sessions (mean 1.8 ± 0.4 sessions; median 2.0 sessions, range 1-2). In four (80%) out five lesions, cross-sectional imaging showed a nearly complete response (CR) while the largest lesion was ablated by 80%. Pain changes were assessed with the Brief Pain Inventory-Short Form, that was administered before IGLA and during a 6-month follow-up. Patients experienced significant reduction in worst pain, average pain, and pain interference. Following IGLA, the average daily opioid requirement rapidly and progressively decreased. Treatments were well-tolerated and no major complications occurred.

CONCLUSIONS

IGLA is an effective and safe debulking procedure and provides significant pain relief in patients suffering from DTC bone metastases that are not responsive to standard treatments. So, IGLA could be considered as part of a multimodality management of advanced thyroid cancer with RR metastatic skeletal involvement.

A Single-Center, 10-Year Retrospective Study on Surgical Treatment and Prognosis Analysis of Differentiated Thyroid Carcinoma with Spinal Metastasis

Objective

Metastatic spinal differentiated thyroid carcinoma (MSDTC) is relatively rare in the clinic and often overlooked. The objective of the current study is to analyze the clinical characteristics and prognosis of patients with MSDTC who underwent surgical treatment to determine the prognostic factors that affect survival.

Methods

This study retrospectively analyzed the clinical data and postoperative follow-up results of MSDTC patients who underwent spinal surgery at the Orthopedic Department of Peking Union Medical College Hospital from January 2010 to January 2020. Clinical data and survival time were analyzed by Kaplan–Meier analysis.

Results

Eleven patients were included, and the average age was 58.3 years (range 37‒74). The average time from the initial surgery to the discovery of spinal metastasis was 42.9 months (range 0‒132), and the average follow-up time was 21.8 months (range 3‒80). Progression was identified in seven patients, and 10 patients (90.9%) died during the follow-up period. Kaplan–Meier analysis showed that extraosseous visceral metastasis (p=0.012), revised Tokuhashi score (p=0.035), Tomita score (p=0.038), and surgical method (p=0.028) were associated with overall survival (OS). In addition, skeletal visceral metastasis (p=0.017), revised Tokuhashi score (p=0.028), Tomita score (p=0.038), and surgical method (p=0.049) were associated with progression-free survival (PFS).

Conclusion

Surgical treatment is an effective method for treating MSDTC and leads to pain relief, restored function and increased spinal stability. Based on our single-center experience, extraosseous visceral metastasis, revised Tokuhashi score, Tomita score, and surgical methods may be potential prognostic factors for OS whilst visceral metastasis, revised Tokuhashi score, Tomita score, and surgical methods may be potential prognostic factors for PFS.

Revision surgery for instrumentation failure after total en bloc spondylectomy: a retrospective case series

Background

There have been several reports of instrumentation failure after three-column resections such as total en bloc spondylectomy (TES) for spinal tumors; however, clinical outcomes of revision surgery for instrumentation failure after TES are seldom reported. Therefore, this study assessed the clinical outcomes of revision surgery for instrumentation failure after TES.

Methods

This study employed a retrospective case series in a single center and included 61 patients with spinal tumors who underwent TES between 2010 and 2015 and were followed up for > 2 years. Instrumentation failure rate, back pain, neurological deterioration, ambulatory status, operation time, blood loss, complications, bone fusion after revision surgery, and re-instrumentation failure were assessed. Data were collected on back pain, neurological deterioration, ambulatory status, and management for patients with instrumentation failure, and we documented radiological bone fusion and re-instrumentation failure in cases followed up for > 2 years after revision surgery.

Results

Of the 61 patients, 26 (42.6%) experienced instrumentation failure at an average of 32 (range, 11–92) months after TES. Of these, 23 underwent revision surgery. The average operation time and intraoperative blood loss were 204 min and 97 ml, respectively. Including the six patients who were unable to walk after instrumentation failure, all patients were able to walk after revision surgery. Perioperative complications of reoperation were surgical site infection (n = 2) and delayed wound healing (n = 1). At the final follow-up, bone fusion was observed in all patients. No re-instrumentation failure was recorded.

Conclusion

Bone fusion was achieved by revision surgery using the posterior approach alone.

Spine stereotactic radiosurgery for metastatic thyroid cancer: a single-institution experience

OBJECTIVE

Patients with metastatic thyroid cancer have prolonged survival compared to those with other primary tumors. The spine is the most common site of osseous involvement in cases of metastatic thyroid cancer. As a result, obtaining durable local control (LC) in the spine is crucial. This study aimed to evaluate the efficacy of spine stereotactic radiosurgery (SSRS) in patients with metastatic thyroid cancer.

METHODS

Information on patients with metastatic thyroid cancer treated with SSRS for spinal metastases was retrospectively evaluated. SSRS was delivered with a simultaneous integrated boost technique using single- or multiple-fraction treatments. LC, defined as stable or reduced disease volume, was evaluated by examining posttreatment MRI, CT, and PET studies.

RESULTS

A total of 133 lesions were treated in 67 patients. The median follow-up duration was 31 months. Dose regimens for SSRS included 18 Gy in 1 fraction, 27 Gy in 3 fractions, and 30 Gy in 5 fractions. The histology distribution was 36% follicular, 33% papillary, 15% medullary, 13% Hurthle cell, and 3% anaplastic. The 1-, 2-, and 5-year LC rates were 96%, 89%, and 82%, respectively. The median overall survival (OS) was 43 months, with 1-, 2-, and 5-year survival rates of 86%, 74%, and 44%, respectively. There was no correlation between the absolute biological equivalent dose (BED) and OS or LC. Patients with effective LC had a trend toward improved OS when compared to patients who had local failure: 68 versus 28 months (p = 0.07). In terms of toxicity, 5 vertebral compression fractures (2.8%) occurred, and only 1 case (0.6%) of greater than or equal to grade 3 toxicity (esophageal stenosis) was reported.

CONCLUSIONS

SSRS is a safe and effective treatment option with excellent LC and minimal toxicity for patients with metastatic thyroid cancer. No association with increased radiation dose or BED was found, suggesting that such patients can be effectively treated with reduced dose regimens.

En Bloc lumpectomy of T12 vertebra for progressive hepatocellular carcinoma metastases following liver transplantation: A case report

RATIONALE

Liver transplantation (LT) is the preferred surgical option for the treatment of early hepatocellular carcinoma (HCC). In contrast, surgical treatment of progressive HCC metastasized to the spine following LT constitutes a considerable challenge. Here, we report the first case of progressive HCC metastasized to the T12 vertebra after local radiotherapy, treated successfully with en bloc lumpectomy following LT for HCC.

PATIENT CONCERNS

A 40-year-old man who had undergone LT for the treatment of HCC 2 months prior presented to our clinic with symptoms of progressive back pain. Magnetic resonance imagining (MRI) and positron emission tomography (PET) examinations showed a solitary metastasis at T12 without recurrence in the liver or metastasis to other organs.

DIAGNOSES

The patient was diagnosed with HCC metastasized to the T12 vertebra after liver transplantation.

INTERVENTIONS

Local radiation therapy of the T12 vertebra was performed; however, the lesion continued to grow one month after irradiation. Accordingly, the patient was treated with en bloc lumpectomy of the T12 vertebra. After surgery, the patient reported significant pain relief. At 11 months post-surgery, a C4 metastasis with spinal cord compression was revealed by MRI. Multiple grafted liver metastases were also detected by ultrasound along with several lung metastases, which were discovered by X-ray. The patient was treated with a pedicle screw system and a mesh cage filled with frozen autografts for C4 metastasis.

OUTCOMES

The patient died 15 months after liver transplantation due to recurrence in the liver and metastasis to the lung.

LESSONS

En bloc lumpectomy may be a viable therapeutic option for patients with progressive solitary spinal metastases after LT refractory to radiotherapy. Use of immunosuppressive therapy after LT may significantly inhibit immune function, making patients more susceptible to HCC recurrence and bone metastasis.

Stereotactic body radiation therapy and minimally invasive surgery in the management of spinal metastases: a change in the paradigm

The main goal of treatment in spinal metastatic patients is local control of the disease, pain relief and the maintenance of ambulation. Traditionally, wide surgical resection of the tumour followed by adjuvant radiation and/or chemotherapy has been recommended. Currently, single-fraction or hypofractionated stereotactic body radiation therapy (SBRT) yields a one-year local control rate of over 95% with minimum morbidity, even for tumours previously considered radioresistant. In addition, by posterolateral and circumferential decompression and stabilisation of the spinal cord, it is feasible to create a 2 to 3 mm epidural margin between the dura mater and the tumour (separation surgery), enough to deliver safe and ablative doses of SBRT to the vertebrae. As these patients tend to be frail, such interventions should ideally be minimally invasive, thereby reducing surgical aggressiveness and helping to minimise the delay of any systemic therapies.

Surgical outcomes and prognostic factors for patients with gastric cancer spinal metastasis

Purpose

To investigate the outcome and prognostic factors of surgery in treating gastric cancer spinal metastasis (GCSM).

Patients and methods

A total of 17 patients with GCSM who have undertaken spinal surgeries have been identified. Kaplan–Meier method and univariate analysis are adopted to investigate the prognostic factors affecting overall survival (OS) and progression-free survival (PFS).

Results

The median PFS and OS are 11.3 months (95% CI: 7.8–14.9 months) and 11.9 months (95% CI: 8.4–15.4 months), respectively. Postoperatively, all patients had substantial pain relief, with mean visual analog scale score descending from 6.6±1.6 to 3.4±1.2. Meanwhile, patients also showed improved neurological functions, with 8 of them having improvements of at least one level in Frankel classification. Univariate analysis presented that patients with carcinoembryonic antigen (CEA)<6 µg/L (p=0.020), lactate dehydrogenase (LDH)<300 U/L (p=0.012), alkaline phosphatase (ALP)<200 U/L (p=0.007), and Tokuhashi score>6 (p=0.027) show longer OS. Moreover, application of bone cement, low level of ALP (<200 U/L), and LDH (<300 U/L) are associated with longer PFS (p<0.05).

Conclusions

Surgery is an efficient option in treating GCSM, due to its efficacy in pain alleviation, function restoration, and stability reconstruction. Low levels of CEA, LDH, ALP, and high Tokuhashi score (>6) are all favorable factors for better OS, whereas low levels of LDH, ALP, and application of bone cement are related with longer PFS.

Prognostic Differences in Patients with Solitary and Multiple Spinal Metastases

Objectives

To investigate the association between the number of metastases to the spine and survival in patients with metastatic spinal cord compression (MSCC), as well as the prognosis difference between patients with solitary spinal metastasis (SSM) and multiple spinal metastases (MSM).

Methods

Three institutional databases were searched to identify all patients who had undergone spinal surgery for metastatic spinal tumors between March 2002 and June 2010. As well as age and gender, preoperative medical conditions were collected from medical records, including primary tumor, preoperative Frankel score, other bone metastases, preoperative Karnofsky performance status (KPS), number of involved vertebrae, pathological fracture metastasis site, serum albumin, sphincter dysfunction and the time of developing motor deficits before surgery. Survival data were obtained from medical records or via telephone follow‐ups. Univariate and multivariate predictors of overall survival for each group were assessed using the Cox proportional hazards model.

Results

The median postoperative survival time was 6.0 ± 0.6 months (95% confidence interval [CI] 4.8–7.2) in patients with SSM and 7.0 ± 1.0 months (95% CI 5.1–8.9) in patients with MSM (P = 0.238). The difference in survival was not significant between groups. Furthermore, univariate analysis showed that the number of spinal metastases had no significant association with survival (P = 0.075). Primary tumor (P = 0.004) and preoperative KPS (P < 0.001) were independent prognostic factors in the whole cohort; primary tumor (P = 0.020), time of developing motor deficit (P = 0.041) and preoperative KPS (P = 0.038) were independent prognostic factors in patients with SSM; while preoperative KPS (P = 0.001) and serum album level (P < 0.001) were independent prognostic factors in patients with MSM.

Conclusion

The number of spinal metastases has not proven to be useful in predicting the prognosis for patients with MSCC. Consequently, more aggressive operations should be considered for patients with multiple spinal metastases.

Surgical Management and Factors Affecting the Prognosis for Patients with Thyroid Cancer Spinal Metastases: A Retrospective Analysis of 52 Consecutive Patients from a Single Center

BACKGROUND

Thyroid cancer, one of the most common endocrine malignancies in developed areas and China, is associated with favorable prognosis. However, the presence of spinal metastases will remarkably reduce the life expectancy for patients with thyroid cancer. In addition, limited information is available about such disease.

METHODS

Various potential clinical factors were submitted to univariate and multivariate analyses to identify the independent variables that predicted the prognosis for patients. In addition, the survival rate was estimated according to the Kaplan-Meier method, and statistic differences were calculated by the log-rank test. Moreover, factors with a P value of ≤0.1 were performed multivariate analysis using a multivariate Cox proportional hazards model, and factors with a P value of <0.05 were considered as statistically significant.

RESULTS

Seven potential independent prognostic factors had been identified through univariate analysis, which were then subjected to multivariate analysis. Our results suggested that age of ≤50 years, single segment involved, and follicular thyroid cancer were the independent favorable prognostic factors.

CONCLUSIONS

Findings in this study indicate that age of ≤50 years, single segment involved, and follicular thyroid cancer are favorable prognostic factors for patients with thyroid cancer spinal metastases.

Total en bloc resection of primary and metastatic spine tumors

Primary and metastatic tumors of the spine represent a significant cause of patient morbidity, and present a management challenge to treating providers. From a neurosurgical standpoint, resection surgery may be warranted in cases of spinal instability, progressive disease, neurological compromise, or intractable symptoms. Removal of a tumor "en bloc" offers a more aggressive modality over more conservative resection techniques. En bloc resection entails the removal of the entirety of a tumor without violation of its capsule, and may offer improved rates of local control and overall survival in appropriately selected patients. Conversely, this technique carries a higher complication rate, and requires a unique set of technical skills as compared to more traditional resection. Here, we describe the technical aspects of en bloc resection, as well as specific indications and considerations when employing this operative technique.

En Bloc Spondylectomy for Spinal Metastases: Detailed Oncological Outcomes at a Minimum of 2 Years after Surgery

Study Design

Retrospective case series.

Purpose

To investigate the oncological outcomes, including distant relapse, after en bloc spondylectomy (EBS) for spinal metastases in patients with a minimum of 2-year follow-up.

Overview of Literature

Although EBS has been reported to be locally curative and extend survival in select patients with spinal metastases, detailed reports regarding the control of distant relapse after EBS are lacking.

Methods

We conducted a retrospective review of 18 consecutive patients (median age at EBS, 62 years; range, 40–77 years) who underwent EBS for spinal metastases between 1991 and 2015. The primary cancer sites included the kidney (n=7), thyroid (n=4), liver (n=3), and other locations (n=4). Survival rates were estimated using the Kaplan–Meier method, and groups were compared using the log-rank method.

Results

The median operative time and intraoperative blood loss were 767.5 minutes and 2,375 g, respectively. Twelve patients (66.7%) experienced perioperative complications. Five patients (27.8%) experienced local recurrence of the tumor at a median of 12.5 months after EBS, four of which had a positive resection margin status. Thirteen patients (72.2%) experienced distant relapse at a median of 21 months after EBS. The estimated median survival period after distant relapse was 20 months (95% confidence interval, 0.71–39.29 months). No association was found between resection margin status and distant relapse. Overall, the 2-year, 5-year, and 10-year survival rates after EBS were 72.2%, 48.8%, and 27.1%, respectively. Importantly, the era in which EBS was performed did not impact the oncological outcomes.

Conclusions

Our results suggest that EBS by itself, even if margin-free, cannot prevent further dissemination, which occurred in >70% of patients at a median of 21 months after EBS. These results should be considered and conveyed to patients for clinical decision-making.

Successful treatment of a diffuse type tenosynovial giant cell tumor in the thoracic spine mimicking spinal metastasis by frozen recapping laminoplasty in a patient with thyroid cancer

PURPOSE

Tenosynovial giant cell tumor of the diffuse type (TGCT-D) involving the spine is rare. Its differential diagnosis includes metastatic disease; however, there have been few reports of spinal TGCT-D mimicking spinal metastasis in patients with a history of malignancy.

METHODS

We report on a 35-year-old woman with a history of papillary thyroid cancer who was diagnosed with TGCT-D of the thoracic spine mimicking spinal metastasis. Preoperative computed tomography (CT) revealed a 1.0 × 1.0-cm lytic bone lesion involving the left T7 vertebral lamina, pedicle, and the T6-7 facet joint; the thoracic spine lesion was markedly fluorodeoxyglucose-avid on positron-emission tomography/computed tomography (PET/CT).

RESULTS

Spinal metastasis was initially suspected given the patient's history of papillary thyroid cancer. Total excision was performed with recapping laminoplasty. The resected lamina was frozen in liquid nitrogen and used as a frozen autograft (frozen recapping laminoplasty) for spinal reconstruction with posterior instrumentation. Histological findings supported a diagnosis of TGCT-D. The patient had no evidence of local recurrence 2 years post-surgery. Bone union was achieved 3 years post-surgery.

CONCLUSIONS

TGCT-D can mimic metastasis in PET/CT and should be included in the differential diagnosis if a lytic lesion affecting the posterior elements of the vertebrae involves the facet joints. CT-guided biopsy is recommended for accurate diagnosis when an occult tumor, such as TGCT, is incidentally detected on PET-CT, even in patients with a history of malignant neoplasm. Frozen recapping laminoplasty is useful for complete resection of a spinal tumor, preventing local recurrence, and preservation of the posterior spinal elements.

En bloc vertebrectomy for the treatment of spinal lesions. Five years of experience in a single institution: a case series

OBJECTIVES

The objective of this study is to describe the experience of a Brazilian public university hospital regarding the treatment of metastatic or benign spine lesions with en bloc vertebrectomy of the thoracic and lumbar spines.

METHODS

This study was a retrospective case series and included all medical records of patients with benign aggressive, primary malignant, or metastatic spine lesions who underwent en bloc vertebrectomy from 2010 to 2015.

RESULTS

A total of 17 patients were included in the analysis. Most of them (71%) were indicated for surgery based on an oncologic resection for localized disease cure. Overall, 10 of the 17 patients (59%) underwent vertebrectomy via an isolated posterior approach using the technique described by Roy-Camille et al. and Tomita et al., while 7 patients (41%) underwent double approach surgeries. Of the 17 patients who underwent the en bloc resection, 8 are still alive and in the outpatient follow-up (47%), and almost all patients with metastatic lesions (8/9) died. The average survival time following the surgical procedure was 23.8 months. Considering the cases of metastatic lesions and the cases of localized disease (malignant or benign aggressive disease) separately, we observed an average survival time of 15 months and 47.6 months respectively.

CONCLUSION

This study demonstrates and reinforces the reproducibility of the en bloc vertebrectomy technique described by Tomita et al.

Risk factors of instrumentation failure after multilevel total en bloc spondylectomy

INTRODUCTION

Multilevel total en bloc spondylectomy (TES) is required to secure oncologically adequate resection margins. However, no useful information has been reported for spinal reconstruction after multilevel TES. Therefore, this study set out to assess the clinical and radiological outcomes of spinal reconstruction after multilevel TES.

METHODS

Forty-eight patients treated with multilevel TES at our institute were included in the analysis. Reconstruction was achieved with posterior pedicle screw fixation and an anterior titanium mesh cage filled with iliac autograft in all cases. Spinal shortening was performed to increase spinal stability from the reconstruction. Instrumentation failure and radiological findings were evaluated with radiography and computerized tomography (CT).

RESULTS

After excluding one patient whose general condition was deteriorating, radiological evaluations of 47 patients were performed over a period of more than a year. The follow-up time was 17 to 120 months (mean: 70.2 months). Instrumentation failure occurred in one patient (5.9%) after thoracic multilevel TES, in 4 patients (25.0%) after thoracolumbar multilevel TES, and in 3 patients (42.9%) after lumbar multilevel TES. No instrumentation failure was observed in cervicothoracic cases. Cage subsidence (>2 mm) occurred in 30 patients (63.8%). In 22 of them, subsidence appeared on the CT one month after surgery. The risk factors of instrumentation failure included a multilevel TES below the thoracolumbar level and a long span of vertebral resection. There was no instrumentation failure in any of the 11 "disc-to-disc cutting" cases.

CONCLUSIONS

This study identified the risk factors of instrumentation failure after multilevel TES. There is a high risk of instrumentation failure in cases of long vertebral resection below the thoracolumbar level. On the other hand, our reconstruction method can be successful for multilevel TES above the thoracic level.

An upper cervical cord compression secondary to occult follicular thyroid carcinoma metastases successfully treated with multiple radioiodine therapies: A clinical case report

RATIONALE

The spine is the most common site of bone metastases due to thyroid cancer; however, spinal cord compression as a complication of metastatic thyroid cancer is very rare.

PATIENT CONCERNS

A 48-year-old female patient was presented to the Neurosurgical Department, complaining of progressive back neck pain with bilateral upper extremities numbness and weakness for 4 months.

DIAGNOSIS

Imaging studies revealed osteolytic destruction in bodies and accessories of the second and third cervical vertebrae with a huge soft-tissue mass compressing spinal cord and causing swelling. After the neurosurgical decompression surgery, the pathological examination established a metastatic follicular carcinoma originating from the thyroid gland.

INTERVENTIONS

Her cervical spinal metastases were hardly removed by surgery and the risks of external beam radiation therapy (EBRT) were very high. So she underwent a total thyroidectomy and received multiple radioiodine (RAI) and concomitant glucocorticoid therapies postoperatively. Radioiodine whole-body scan (WBS) showed multiple abnormal radioiodine uptakes. Then single-photon emission tomography/computed tomography (SPECT/CT) located these spinal metastases involving cervical, lumbar, and sacral vertebrae.

OUTCOMES

After 5 times RAI therapy, her thyroglobulin obviously decreased, with the cervical lesion shrinkage and no spinal cord edema.

LESSONS

RAI therapy and concomitant glucocorticoid therapy could be used for spinal metastases of FTC, even with spinal cord compression.

Complete Spondylectomy Using Orthogonal Spinal Fixation and Combined Anterior and Posterior Approaches for Thoracolumbar Spinal Reconstruction: Technical Nuances and Clinical Results

STUDY DESIGN

Retrospective chart review.

OBJECTIVE

To determine the long-term efficacy of 2-stage total en bloc spondylectomy (TES).

SUMMARY OF BACKGROUND DATA

TES is a well-described technique to achieve tumor-free margins, but it is a highly destabilizing procedure that necessitates spinal reconstruction. A 2-stage anterior/posterior approach for tumor resection and instrumentation has been shown to be biomechanically superior to the single-stage approach in achieving rigid fixation, but few clinical studies with long-term outcomes exist.

METHODS

A retrospective review was performed on patients undergoing a 2-stage TES for a spinal tumor between 1999 and 2011. Results were compared with those from a literature review of case series, with a minimum of 2-year follow-up, reporting on a single-stage posterior-only approach for TES.

RESULTS

Seven patients were identified (average follow-up 52.7 mo). Tumor location ranged from T1 to L3 with the following pathologies: metastasis (n=3), hemangioma (n=1), leiomyosarcoma (n=1), giant cell tumor (n=1), and chordoma (n=1). There were no significant surgical complications. All 7 patients had intact spinal fixation. There were no failures of the orthogonal fixation (pedicle screws or anterior fixation). The average modified Rankin Scale scores improved from 2.7 preoperatively to 0.7 at last follow-up. None of the patients in our series suffered local disease recurrence at last follow-up or suffered neurological deterioration. These results were comparable with those noted in the literature review of posterior-only approach, where 12% of patients experienced instrument failure.

CONCLUSIONS

TES is a highly destabilizing procedure requiring reconstruction resistant to large multiplanar translational and torsional loads. A 2-stage approach utilizing orthogonal vertebral body screws perpendicular to pedicle screws is a safe and effective surgical treatment strategy. Orthogonal spinal fixation may lower the incidence of instrumentation failure associated with complete spondylectomy and appears to be comparable with a single-stage procedure. However, larger prospective series are necessary to assess the efficacy of this approach versus traditional means.

Surgery Combined with Radiotherapy to Treat Spinal Tumors: A Review of Published Reports

Spinal tumors result in high morbidity and a high rate of lower limb paralysis. Both surgical therapy and radiation therapy (RT) are used to treat spinal tumors; however, how best to combine these two therapies to maximize the benefits and minimize the risks is still being debated. It is also difficult to decide the optimal timing, course and dose of RT, especially in pregnant women and children. The aim of this review is to assist surgeons who are dealing with spinal tumors by providing comprehensive information about advanced techniques for administering RT with greater precision and safety, and about the impact of various ways of combining surgery and RT on therapeutic outcomes. We here review published reports about treating spinal tumors with a combination of these two forms of therapy and attempt to draw appropriate conclusions concerning selection of optimal treatment protocols. Our conclusion is that postoperative radiotherapy, especially with high-precision, low-dose and multiple fractions, and brachytherapy are promising therapies to combined with surgery.

Local treatment of metastases from differentiated thyroid cancer

OBJECTIVES

To study the various local treatments available for thyroid cancer metastases, investigate techniques and assess their advantages and limitations and roles in the overall treatment strategy for metastatic disease.

RESULTS

We investigated metastases surgery, external radiation therapy, embolization, chemoembolization, cementoplasty, radiofrequency ablation and cryotherapy, describing techniques, advantages and drawbacks and possible complications. Indications were reviewed according to metastases location, and the roles of the various techniques are discussed in the overall treatment strategy for thyroid cancer metastases. Despite the advent of new targeted therapies, local treatment still has an important role to play: either palliative or, in oligometastatic involvement, curative. Even in extensive disease, it may allow postponement of tyrosine kinase inhibitor therapy, which, once initiated, has to be continued life-long, is expensive and is not free of side-effects.

[Total en bloc spondylectomy for spinal tumours: Technical aspects and surgical details]

OBJECTIVE

To describe the specific surgical details and report the lessons learned with a series of patients suffering from spinal tumours that underwent total en bloc spondylectomy (TES).

METHODS

A retrospective case series review is presented, together with an analysis of the clinical and technical variables, as well as the outcomes.

RESULTS

A total of 10 patients underwent TES (2000-2016) for primary (osteosarcoma, chondrosarcoma, fibrosarcoma and chordoma) and secondary spinal tumours (lung, breast, thyroid, oesophagus, and meningioma metastases). According to the Tomita classification, 2 patients had intra-compartmental tumours, and the rest presented as extra-compartmental. All patients experienced an improvement in their pain level after surgery. Nine patients preserved ambulation post-operatively and one patient developed paraplegia. Six patients needed subsequent operations for wound debridement, tumour recurrence, or revision of the fixation. Other complications included pneumothorax, pleural effusion and venous thrombosis. Four patients remain alive (4 months to 15 years follow-up). The rest died due to primary tumour progression (6.5 months to 12 years). A detailed description of the surgical steps, tips, and pitfalls is provided. Modifications of the technique and adjuncts to resection are commented on. Observation of some considerations (selection of candidates, careful blunt vertebral dissection, strict blood loss control, careful handling of the spinal cord, and maintenance of the radical resection concept at all stages) is key for a successful operative performance.

CONCLUSION

TES is a paradigmatic operation, in which the concept of radical resection provides functional effectiveness and improves survival in selected patients suffering from spinal tumours. Our preliminary experience allows us to highlight some specific and relevant features, especially those favouring a simpler and safer operation.

The use of spine stereotactic radiosurgery for oligometastatic disease

OBJECTIVE

The authors investigated the outcomes following spine stereotactic radiosurgery (SSRS) for patients with oligometastatic disease of the spine.

METHODS

The study was a secondary analysis of 38 of 209 patients enrolled in 2 separate institutional Phase I/II prospective protocols and treated with SSRS between 2002 and 2011. Of these 38 patients, 33 (87%) were treated for a solitary spine metastasis, with no other history of metastatic disease. SSRS was prescribed to 24 Gy in 1 fraction (8%), 18 Gy in 1 fraction (18%), 16 Gy in 1 fraction (11%), 27 Gy in 3 fractions (53%), 30 Gy in 5 fractions (8%), or 20 Gy in 5 fractions (3%). Seventeen patients (45%) received prior conventional external beam radiation therapy.

RESULTS

The median overall survival (OS) was 75.7 months, and the 2- and 5-year OS rates were 84% and 60%, respectively. In multivariate analysis, patients who had prior spine surgery and a better Karnofsky Performance Scale score had an improved OS (HR 0.16, 95% CI 0.05–0.52, p < 0.01, and HR 0.33, 95% CI 0.13%–0.84%, p = 0.02, respectively), and those who had undergone prior radiation therapy had a worse OS (HR 3.6, 95% CI 1.2%–10%, p = 0.02). The 1-, 2-, and 5-year local progression-free survival rates were 85%, 82%, and 78%, respectively. The median time to systemic therapy modification was 41 months. Two patients (5%) experienced late Grade 3–4 toxicity.

CONCLUSIONS

Patients with oligometastatic disease of the spine treated with SSRS can experience long-term survival and a long time before needing a modification in systemic therapy. In addition, SSRS leads to excellent local control and minimal late toxicity.

The impact of complete surgical resection of spinal metastases on the survival of patients with thyroid cancer

Spinal metastases (SMs) from thyroid cancers significantly reduce the quality of life by causing pain and neurological deficits and increase mortality. Complete surgical resection of isolated thyroid SMs is a promising treatment option; however, the postoperative outcome is unknown. This study aimed to compare the postoperative courses of patients undergoing complete resection of thyroid SMs with those of patients undergoing incomplete resection, with a minimum 4‐year follow‐up. We performed a retrospective analysis of 32 patients who underwent tumor excision surgery for thyroid SMs at our medical center during a 28‐year period. Twenty patients underwent complete excision, and 12 underwent incomplete excision. Survival was defined as the time from the first spinal surgery to death or last follow‐up. Kaplan–Meier analysis with the long‐rank test was used to compare the overall survival rates between the groups. For all patients, the overall 5‐ and 10‐year survival rates were 71% and 31%, respectively. The median overall survival time was 6.4 years. The patients undergoing complete excision survived longer than those undergoing incomplete excision (5‐year survival: 84% vs. 50%; 10‐year survival: 52% vs. 8%; P < 0.01). Only one patient undergoing complete excision experienced local tumor recurrence in the operated spine, whereas all long‐term survivors (>18 months after surgery) in the incomplete excision group experienced local tumor recurrence and a consequent deterioration in performance status. Complete surgical resection of thyroid SMs, if achievable, has the potential not only to maintain performance status, but also to prolong survival.

Predictors for surgical complications of en bloc resections in the spine: review of 220 cases treated by the same team

PURPOSE

Identify risk factors, enabling reduction of the rate of complications and improve outcome in en bloc resection surgeries.

METHODS

A retrospective study of prospective collected data of 1681 patients affected by spine tumors treated from 1990 to 2015 by the same team.

RESULTS

A total of 220 en bloc resections that were performed on 216 patients during that period. Most of the tumors were primary-165 cases (43 benign and 122 malignant), metastases occurred in 55 cases. Median FU was 45 months (0-371). 153 complications were observed in 100 patients (46.2 %). 64 (30 %) suffered one complication, while the rest had two or more. There were 105 major and 48 minor complications. Seven patients (4.6 %) died as a result of complications. The combined approach, neoadjuvant chemotherapy and neoadjuvant radiotherapy were statistically significant independent risk factors for complications occurrence. 33 patients (15.2 %) suffered from local recurrence. Reoperations were mostly due to tumor recurrences, but also to hardware failures, wound dehiscence, hematomas and aortic dissection.

CONCLUSION

The rate of complication is higher in multisegmental resections and when double combined approach is performed. Reoperations display greater morbidity owing to dissection through scar/fibrosis from previous operations and possibly from RT. Careful treatment planning and, in the event of uncertainty, referral to a specialty center must be stressed. The high risk of complications should not discourage surgeons from performing en bloc resection when needed. Most of the patients who sustain complications benefit from the better local control resulting from en bloc resection.

Is there a relationship between spinal instability in neoplastic disease and Tokuhashi scoring system?

Spinal instability neoplastic score (SINS) classification evaluates spinal stability by adding together six radiographic and clinical components. The objective of this study was to verify the association between SINS and Tokuhashi scoring system (TSS) score. Fifty-eight patients with vertebral metastases were admitted from 2010 to 2014 at Hospital do Servidor Público Estadual de São Paulo. They were evaluated according to their SINS and Tokuhashi SS score. Fourteen patients (24.13 %) scored from 0 to 6 points (stable spine), 37 (63.79 %) scored from 7 to 12 (potentially unstable), and 7 (12.06 %) scored from 13 to 18 (unstable). In stable spine patients according to SINS, the mean TSS score was 9.2. In potentially unstable spine patients, the mean TSS score was 8.24. In unstable spine patients, mean TSS score was 6.28. There was a statistically significant difference of the TSS score between stable and unstable patients. After evaluating TSS score in each patient, the worse the SINS, the worse was also the TSS score.

Therapy for thoracic lumbar and sacral vertebrae tumors using total spondylectomy and spine reconstruction through posterior or combined anterior-posterior approaches

The present study aimed to analyze the indications, feasibility, safety and clinical effects of total spondylectomy and spine reconstruction through posterior or combined anterior-posterior approaches for thoracic lumbar and sacral vertebrae tumors. Between December 2009 and May 2012, 10 patients with thoracic lumbar and sacral vertebrae tumors were retrospectively analyzed. Different surgical indications and approaches were used according to the affected segments, the extent of lesion involvement and the specific pathology results. One-stage posterior or combined anterior-posterior total spondylectomy and reconstruction was used for the treatment of complicated thoracic lumbar and sacral vertebral malignant tumors and invasive benign tumors. The duration of surgery, levels of intraoperative blood loss and transfusions, and the clinical effects were observed. The average surgical duration was 6.8 h (range, 4.8-12 h), with an average blood loss level of 3,200 ml (range, 1,500-10,000 ml) and an average transfusion level of 2,500 ml. During the average 15 months (range, 3-29 months) follow up, two patients succumbed and one patient experienced tumor recurrence. Neither tumor reoccurrence nor metastasis was observed in all other patients. Personalized surgical indications and approaches according to the affected segments, the extent of lesion involvement and the specific pathology results would aid in the reduction of pain, the improvement of nerve function and the reduction of tumor recurrence.

Recurrent spinal metastasis of a sporadic medullary carcinoma of the thyroid after radiation therapy: a case report and review of the literature

Sporadic Medullary Carcinoma of the Thyroid is a relatively uncommon entity and at the time of diagnosis, most already present loco-regional metastasis. Therapy should be aggressive to reduce recurrence and mortality. Follow-up period should continue lifelong and should also include calcium/pentagastrin infusion test, as well as 6-month interval diagnostic imaging.

Follicular thyroid carcinoma presenting as acute cord compression due to thoracic vertebral metastasis

Thyroid carcinoma is uncommon but accounts for roughly 95% of all cancers of the endocrine system (1). The “well-differentiated” thyroid tumors include the papillary, follicular, and Hurthle cell subtypes. Although the management of these tumor types generally is similar, important diagnostic and clinical differences do exist (2). We present a case of follicular thyroid carcinoma with spinal metastasis, illustrate its imaging features on CT and MR imaging with histologic correlations, and discuss how vertebral osseous metastasis may influence clinical management of patients with differentiated thyroid cancer.

Total En Bloc Spondylectomy for Primary and Metastatic Spine Tumors

This study reports the surgical and clinical outcomes of spinal tumors managed with total en bloc spondylectomy. The authors searched their prospectively maintained database for patients undergoing total en bloc spondylectomy between 2001 and 2013. Ten patients (9 men, 1 woman; average age, 50.7 years; range, 42-68 years) were identified. The authors obtained demographic information, surgical outcomes (estimated blood loss, complications), and clinical outcomes (recurrence, survival). All patients had pain and were classified as American Spinal Injury Association grade E. The lesions were located in the thoracic (8 patients) and lumbar (2 patients) spine. Anterior column reconstruction was performed with strut allograft (7 patients), mesh cage (2 patients), and polymethyl methacrylate (1 patient). An average of 2.3 (range, 2-4) of 6 portions of the vertebrae were involved, according to the Kostuik classification. Mean estimated blood loss, operative time, and hospital stay were 3.5 L, 500 minutes, and 7.8 days, respectively. Perioperative complications included pleural tear (2 patients) and aortic tear, vena cava tear, retained sponge, pulmonary embolism, urinary tract infection, pneumothorax, anterior column support failure, and prominent instrumentation requiring removal (1 patient each). Postoperatively, all patients remained classified as American Spinal Injury Association grade E. Two patients had recurrence at distant spinal segments, and 1 had a new lesion in the thigh. Five patients had died (mean, 34.5 months after surgery), and 5 were alive a mean of 19.6 months after surgery (range, 6-48 months). Total en bloc spondylectomy is challenging, but in appropriately selected patients, it can be used to treat primary and metastatic spinal lesions.

Metastasis of differentiated thyroid cancer in the subchondral bone of the femoral head: a case report

Background

Differentiated thyroid cancer (DTC) is relatively rare and can metastasize to both the lungs and bones. The great majority of bone metastases occur in red marrow regions where blood flow is high. Only one patient has been described with direct DTC metastasis to the subchondral bone of the femoral head.

Case presentation

The patient was a 68-year-old Japanese female who had presented with left hip joint pain at age 63 years. At age 51 years, she had been diagnosed with DTC and underwent partial excision. X-rays showed partial femoral head collapse, suggesting osteoarthritis or idiopathic necrosis of the left femoral head. Three years later, a ¹³¹ I whole-body scan showed accumulation in the left femoral head, resulting in a diagnosis of DTC metastasis to the left femoral head. Bipolar hip arthroplasty was performed. Examination of the excised femoral head resulted in a final diagnosis of metastasis of follicular thyroid cancer, which was limited histopathologically to the subchondral bone of the femoral head.

Conclusion

Tumor metastasis to the subchondral bone of the femoral head is exceedingly rare. Overall survival of patients with bone metastasis is improved by complete resection. Differential diagnosis of patients with a previous history of DTC who present with femoral head collapse should include bone metastasis of DTC.