Factors affecting survival in 43 consecutive patients after surgery for spinal metastases from thyroid carcinoma

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.

The effect of timing between preoperative embolization and surgery: A retrospective analysis of hypervascular bone metastases

BACKGROUND AND OBJECTIVES

The optimal timing between preoperative embolization of hypervascular metastatic bone lesions and surgery has yet to be established. Our analysis sought to evaluate embolization timing impacts blood loss, transfusion risk, and operative time in patients with hypervascular primary tumors.

METHODS

We identified patients with renal cell (RCC) or thyroid carcinoma undergoing surgery between 1992 and 2023. Patients were segregated into the following cohorts: (1) no embolization preoperatively, (2) surgery <24 h of embolization, and (3) surgery >24 h after embolization. Multivariate logistic regression analyses were performed to assess the effect of embolization timing while controlling for confounding variables.

RESULTS

No differences were seen in all evaluated outcomes between immediate and delayed embolization cohorts. No differences in estimated blood loss were seen between the immediate (OR: 0.685, 95% CI: 0.159-2.949; p = 0.611) and delayed (OR: 0.568, 95% CI: 0.093-3.462; p = 0.539) surgery cohorts compared with patients without embolization. Surgery >24 h after embolization was not associated with a higher risk of prolonged operative time (OR: 13.499, 95% CI: 0.832-219.146; p = 0.067).

CONCLUSIONS

These findings suggest that surgery may be safely delayed beyond 24 h from embolization without a higher risk of bleeding. In appropriately selected cohorts, embolization may not be needed preoperatively.

Oncologic and Functional Outcomes After Stereotactic Body Radiation Therapy for High-Grade Malignant Spinal Cord Compression

Purpose

Although surgical decompression is the gold standard for metastatic epidural spinal cord compression (MESCC) from solid tumors, not all patients are candidates or undergo successful surgical Bilsky downgrading. We report oncologic and functional outcomes for patients treated with stereotactic body radiation therapy (SBRT) to high-grade MESCC.

Methods and Materials

Patients with Bilsky grade 2 to 3 MESCC from solid tumor metastases treated with SBRT at a single institution from 2009 to 2020 were retrospectively reviewed. Patients who received upfront surgery before SBRT were included only if postsurgical Bilsky grade remained ≥2. Neurologic examinations, magnetic resonance imaging, pain assessments, and analgesic usage were assessed every 3 to 4 months post-SBRT. Cumulative incidence of local recurrence was calculated with death as a competing risk, and overall survival was estimated by Kaplan-Meier.

Results

One hundred forty-three patients were included. The cumulative incidence of local recurrence was 5.1%, 7.5%, and 14.1% at 6, 12, and 24 months, respectively. At first post-SBRT imaging, 16.2% of patients with initial Bilsky grade 2 improved to grade 1, and 53.8% of patients were stable. Five of 13 patients (38.4%) with initial Bilsky grade 3 improved to grade 1 to 2. Pain response at 3 and 6 months post-SBRT was complete in 45.4% and 55.7%, partial in 26.9% and 13.1%, stable in 24.1% and 27.9%, and worse in 3.7% and 3.3% of patients, respectively. At 3 and 6 months after SBRT, 17.8% and 25.0% of patients had improved ambulatory status and 79.7% and 72.4% had stable status.

Conclusions

We report the largest series to date of patients with high-grade MESCC treated with SBRT. The excellent local control and functional outcomes suggest SBRT is a reasonable approach in inoperable patients or cases unable to be successfully surgically downgraded.

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.

Systemic considerations for the surgical treatment of spinal metastatic disease: a scoping literature review

Systemic assessment is a pillar in the neurological, oncological, mechanical, and systemic (NOMS) decision-making framework for the treatment of patients with spinal metastatic disease. Despite this importance, emerging evidence relating systemic considerations to clinical outcomes following surgery for spinal metastatic disease has not been comprehensively summarised. We aimed to conduct a scoping literature review of this broad topic. We searched MEDLINE, Embase, Scopus, Cochrane Central Register of Controlled Trials, Web of Science, and CINAHL databases from Jan 1, 2000, to July 31, 2021. 61 articles were included, accounting for a total of 22 335 patients. Preoperative systemic variables negatively associated with postoperative clinical outcomes included demographics (eg, older age [>60 years], Black race, male sex, low or elevated body-mass index, and smoking status), medical comorbidities (eg, cardiac, pulmonary, hepatic, renal, endocrine, vascular, and rheumatological), biochemical abnormalities (eg, hypoalbuminaemia, atypical blood cell counts, and elevated C-reactive protein concentration), low muscle mass, generalised motor weakness (American Spinal Cord Injury Association Impairment Scale grade and Frankel grade) and poor ambulation, reduced performance status, and systemic disease burden. This is the first comprehensive scoping review to broadly summarise emerging evidence relevant to the systemic assessment component of the widely used NOMS framework for spinal metastatic disease decision making. Medical, surgical, and radiation oncologists can consider these findings when prognosticating spinal metastatic disease-related surgical outcomes on the basis of patients' systemic condition. These factors might inform a shared decision-making approach with patients and their families.

The performance of frailty in predictive modeling of short-term outcomes in the surgical management of metastatic tumors to the spine

BACKGROUND CONTEXT

The concept of frailty has become increasingly recognized, and while patients with cancer are at increased risk for frailty, its influence on perioperative outcomes in metastatic spine tumors is uncertain. Furthermore, the impact of frailty can be confounded by comorbidities or metastatic disease burden.

PURPOSE

The purpose of this study was to evaluate the influence of frailty and comorbidities on adverse outcomes in the surgical management of metastatic spine disease.

STUDY DESIGN/SETTING

Retrospective analysis of a nationwide database to include patients undergoing spinal fusion for metastatic spine disease.

PATIENT SAMPLE

A total of 1,974 frail patients who received spinal fusion with spinal metastasis, and 1,975 propensity score matched non-frail patients.

OUTCOME MEASURES

Outcomes analyzed included mortality, complications, length of stay (LOS), nonroutine discharges and costs.

METHODS

A validated binary frailty index (Johns Hopkins Adjusted Clinical Groups) was used to identify frail and non-frail groups, and propensity score-matched analysis (including demographics, comorbidities, surgical and tumor characteristics) was performed. Sub-group analysis of levels involved was performed for cervical, thoracic, lumbar and junctional spine. Multivariable-regression techniques were used to develop predictive models for outcomes using frailty and the Elixhauser Comorbidity Index (ECI).

RESULTS

7,772 patients underwent spinal fusion with spinal metastasis, of which 1,974 (25.4%) patients were identified as frail. Following propensity score matching for frail (n=1,974) and not-frail (n=1,975) groups, frailty demonstrated significantly greater medical complications (OR=1.58; 95% CI 1.33-1.86), surgical complications (OR=1.46; 95% CI 1.15-1.85), LOS (OR=2.65; 95% CI 2.09-3.37), nonroutine discharges (OR=1.79; 95% CI 1.46-2.20) and costs (OR=1.68; 95% CI 1.32-2.14). Differences in mortality were only observed in subgroup analysis and were greater in frail junctional and lumbar spine subgroups. Models using ECI alone (AUC=0.636-0.788) demonstrated greater predictive ability compared to those using frailty alone (AUC=0.633-0.752). However, frailty combined with ECI improved the prediction of increased LOS (AUC=0.811), cost (AUC=0.768), medical complications (AUC=0.723) and nonroutine discharges (AUC=0.718). Predictive modeling of frailty in subgroups demonstrated the greatest performance for mortality (AUC=0.750) in the lumbar spine, otherwise performed similarly for LOS, costs, complications, and discharge across subgroups.

CONCLUSIONS

A high prevalence of frailty existed in the current patient cohort. Frailty contributed to worse short-term adverse outcomes and could be more influential in the lumbar and junctional spine due to higher risk of deconditioning in the postoperative period. Predictions for short term outcomes can be improved by adding frailty to comorbidity indices, suggesting a more comprehensive preoperative risk stratification should include frailty.

Factors associated with spinal fixation mechanical failure after tumor resection: a systematic review and meta-analysis

Background

No available meta-analysis has been published that systematically assessed spinal fixation mechanical failure after tumor resection based on largely pooled data. This systematic review and meta-analysis aimed to investigate the spinal fixation failure rate and potential risk factors for hardware failure.

Methods

Electronic articles published between January 1, 1979, and January 30, 2021, were searched and critically evaluated. The authors independently reviewed the abstracts and extracted data on the spinal fixation failure rate and potential risk factors.

Results

Thirty-eight studies were finally included in the meta-analysis. The pooled spinal fixation mechanical failure rate was 10%. The significant risk factors for hardware failure included tumor level and cage subsidence. Radiotherapy was a potential risk factor.

Conclusion

The spinal fixation mechanical failure rate was 10%. Spinal fixation failure is mainly associated with tumor level, cage subsidence and radiotherapy. Durable reconstruction is needed for patients with these risk factors.

Separation Surgery in the Treatment of Spinal Metastasis

The life expectancy of patients with advanced cancer has been prolonged with the development of systemic treatment technology. Spinal metastasis is one of the common ways of metastasis of advanced tumors, leading to spinal cord compression and compression fractures, which often lead to a significant reduction in patients’ quality of life and physical function. Therefore, surgical treatment is still needed for functional recovery and local control. Separation surgery has been known since 2014 when it was purposed. Combined with radiotherapy, it can achieve an ideal goal of local control. This paper gives a brief introduction to separation surgery, hoping to increase the reader's understanding and consider this method in the course of treatment.

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.

Spinal metastases 2021: a review of the current state of the art and future directions

Spinal metastases are an increasing societal health burden secondary to improvements in systemic therapy. Estimates indicate that 100,000 or more people have symptomatic spine metastases requiring management. While open surgery and external beam radiotherapy have been the pillars of treatment, there is growing interest in more minimally invasive technologies (eg separation surgery) and non-operative interventions (eg percutaneous cementoplasty, stereotactic radiosurgery). The great expansion of these alternatives to open surgery and the prevalence of adjuvant therapeutic options means that treatment decision making is now complex and reliant upon multidisciplinary collaboration. To help facilitate construction of care plans that meet patient goals and expectations, clinical decision aids and prognostic scores have been developed. These have been shown to have superior predictive value relative to more classic prediction models and may become an increasingly important aspect of the clinical practice of spinal oncology. Here we overview current therapeutic advances in the management of spine metastases and highlight emerging areas for research. Given the rapid advancements in surgical technologies and adjuvants, the field is likely to undergo further transformative changes in the coming decade.

What Predicts the Prognosis of Spinal Metastases in Separation Surgery Procedures?

BACKGROUND

Separation surgery is performed to provide a safe gap between the epidural tumor and spinal cord for postoperative stereotactic body radiotherapy (SBRT) in cases of spinal metastases. However, there is a gap in evidence regarding sufficient tumor resection in separation surgery. We describe the prognoses according to the extent of resection in separation surgery.

METHODS

This retrospective study included 36 consecutive patients who underwent separation surgery and postoperative SBRT between December 2016 and December 2019 at a single center. Local control (LC), overall survival (OS), distance of separation (DS), and quality-of-life parameters were analyzed. P values <0.05 were considered statistically significant.

RESULTS

Patients were assigned to the aggressive resection group (ARG, n = 18) or moderate resection group (MRG, n = 18), with estimated LC and OS at 1 year of 79.0% and 75.9%, respectively. There were no significant differences between ARG and MRG in estimated LC (85.9% vs. 72.2%; P = 0.317) or OS (69.3% vs. 80.9%, P = 0.953) at 1 year. All 5 patients in MRG who developed local progression had less satisfactory tumor resection with DS <3 mm. A borderline significant difference in estimated LC at 1 year was noted between individuals with DS <3 mm and those with DS ≥3 mm (51.9% vs. 100.0%; P = 0.053) in MRG. There was no statistical difference between ARG and MRG in quality-of-life parameters.

CONCLUSIONS

Moderate resection of ventral dural mass did not significantly reduce patients' prognosis in separation surgery. However, the minimal distance between the postoperative residual epidural tumor and spinal cord should be ≥3 mm.

Prognostic Factors in Patients with Differentiated Thyroid Cancers Metastatic to the Cervical Spine

OBJECTIVES

The spine is the most common site of bone metastases in differentiated thyroid cancer (DTC). The role of surgery in the management of cervical spine (C-spine) metastases (CSpM) has not been adequately explored.

METHODS

This is a retrospective cohort study at a tertiary referral center from 2002 to 2018. Inclusion criteria were pathologic diagnosis of DTC and imaging/pathologic diagnosis of CSpM. Statistical analysis utilized t tests for continuous variables and χ² tests for categorical variables. Survival analysis was conducted using Kaplan-Meier curves with univariate and multivariate Cox regressions.

RESULTS

Fifty patients with DTC and CSpM were identified. Of those, 16 underwent surgical resection of the C-spine, whereas 34 did not. The most common presenting symptom was neck pain (N = 37, 74%). Patients in the surgery group were more likely to report a subjective improvement of symptoms (P < .01) and to have local (P < .01) and systemic (P = .04) disease control. Five-year overall survival was 44.7% for the surgery group (95% confidence interval [CI]: 17.1-69.3) and 11.1% (95% CI: 2.1-28.8) for the nonsurgery group (P = .01). The strongest risk factor for improved overall survival after C-spine metastasis was local disease control at the C-spine (multivariate hazard ratio [HR] = 0.32, 95% CI: 0.12-0.85, P = .02). Surgical intervention was significantly associated with improved survival on both univariate (HR = 0. 35, 95% CI: 0.15-0.82, P = .02) and multivariate (HR = 0.37, 95% CI: 0.14-0.98, P = .04) analysis.

CONCLUSION

Surgical management of CSpM in differentiated thyroid cancers is associated with significantly improved local disease control and overall survival. Referral to spine surgeons should be considered after diagnosis.

LEVEL OF EVIDENCE

IV. Laryngoscope, 131:E1741-E1747, 2021.

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.

Necessity of Bony Fusion After Surgical Treatment of Metastatic Spine Tumors

INTRODUCTION

The role of bony fusion in influencing patient outcome and surgical revision rates in the treatment of metastatic spine disease is poorly defined. The goals of this study were, therefore, to evaluate the effect of fusion on revision surgery as well as on overall survival (OS) and functional status in patients with metastatic disease of the spine.

METHODS

A retrospective cohort study of a prospective database at a major cancer center was conducted. A total of 25 patients who met the inclusion criteria from January 2010 to December 2015 were included. Functional status, patient and tumor characteristics, fusion status, and survival were analyzed, and regression analyses were done. Bony fusion was classified as either present (seen across a minimum of three levels and crossing the tumor site) or absent as evidenced through CT images at minimum of 1-year postoperatively.

RESULTS

Twenty-five subjects with 28 surgical sites met the eligibility criteria to be included in this study cohort. Five surgical sites were found to have evidence of fusion on CT scans at 1 year after surgery, and 23 sites had no evidence of bridging fusion. No differences were found between the two groups in terms of OS, and ambulatory status (P > 0.10). Multivariate analysis did not reveal any specific factors affecting fusion. Mean follow-up was 23.7 months.

DISCUSSION

The lack of bony fusion is not an independent predictor of the need for revision surgery. The lack of bony fusion in patients with metastatic disease of the spine does not appear to negatively affect their OS or their ambulatory status. A discussion of factors affecting fusion is complex, and there are other factors that may also play a role. Large multicenter trials are needed to corroborate the preliminary findings seen in this complex patient cohort.

Natural disease progression and novel survival prediction model for hepatocellular carcinoma with spinal metastases: a 10-year single-center study

BACKGROUND

Individual prediction of life expectancy in patients with spinal metastases from hepatocellular carcinoma (HCC) is key for optimal treatment selection, especially when identifying potential candidates for surgery. Most reported prognostic tools provide categorical predictions, and only a few include HCC-related factors. This study aimed to investigate the natural progression of the disease and develop a prognostic tool that is capable of providing individualized predictions.

METHODS

Patients with HCC-derived metastatic spinal disease were identified from a retrospective cohort of patients with spinal metastases who were diagnosed at Chiang Mai University Hospital between 2006 and 2015. Kaplain-Meier methods and log-rank tests were used to statistically evaluate potential factors. Significant predictors from the univariable analysis were included in the flexible parametric survival regression for the development of a prognostic prediction model.

RESULTS

Of the 1143 patients diagnosed with HCC, 69 (6%) had spinal metastases. The median survival time of patients with HCC after spinal metastases was 79 days. In the multivariable analysis, a total of 11 potential clinical predictors were included. After backward elimination, four final predictors remained: patients aged > 60 years, Karnofsky Performance Status, total bilirubin level, and multifocality of HCC. The model showed an acceptable discrimination at C-statistics 0.73 (95% confidence interval 0.68-0.79) and fair calibration.

CONCLUSION

Four clinical parameters were used in the development of the individual survival prediction model for patients with HCC-derived spinal metastases of Chiang Mai University or HCC-SM CMU model. Prospective external validation studies in a larger population are required prior to the clinical implication of the model.

Visceral Metastasis: A Prognostic Factor of Survival in Patients with Spinal Metastases

Objective

To characterize the visceral metastasis as a predictive tool for the survival of patients with spinal metastases through an exploratory meta‐analysis.

Methods

Two investigators independently searched PubMed and Embase databases for eligible studies from 2000–2016. The effect estimates for the hazard ratio (HR) or risk ratio (RR) and 95% confidence interval (CI) were collected and pooled with a random‐ or fixed‐effect model.

Results

In total, 18 eligible studies were retrieved with 5468 participants from nine countries. The overall pooled effect size for HR and RR was 1.50 and 3.79, respectively, which was proved to be statistically significant. In the subgroup of prostate cancer (PCa) and non‐small cell lung cancer (NSCLC), statistical significance and marginal statistical significance was presented for the pooled HR (HR = 1.76, 95% CI 1.35–2.29) and (RR = 1.56, 95% CI 0.99–2.48), respectively. However, in the subgroup of thyroid cancer, breast cancer, and renal cancer, statistical significance was not achieved (HR = 1.17, 95% CI 0.75–1.83, Z = 0.70, P = 0.486). The results did not show any evidence of publication bias.

Conclusions

This study demonstrated that visceral metastasis was a significant prognostic factor in patients with spinal metastases as a whole. Interestingly, the onset of visceral metastases differentially impacted the survival in different primary tumors. Therefore, the prognostic value of visceral metastasis might be related to the type of primary tumor.

Instrumented surgical treatment for metastatic spinal tumors: is fusion necessary?

OBJECTIVE

The goal of this study was to evaluate the radiographic and clinical results of instrumentation surgery without fusion for metastases to the spine.

METHODS

Between 2010 and 2017, patients with spinal tumors who underwent instrumentation without fusion surgery were consecutively evaluated. Preoperative and postoperative clinical data were evaluated. Data were inclusive for last follow-up and just prior to death if the patient died. Instrumentation-related complications included screw migration, screw or rod breakage, cage migration, and screw loosening.

RESULTS

Excluding patients who died within 6 months, a total of 136 patients (140 operations) were recruited. The average follow-up duration was 16.5 months (median 12.4 months). The pain visual analog scale score decreased from 6.4 to 2.5 (p < 0.001) and the Eastern Cooperative Oncology Group scale score improved (p < 0.001). There were only 3 cases (2.1%) of symptomatic instrumentation-related complications that resulted in revisions. There were 6 cases of nonsymptomatic complications. The most common complication was screw migration or pull-out (5 cases). There were 3 cases of screw or rod breakage and 1 case of cage migration. Two-thirds of the cases of instrumentation-related complications occurred after 6 months, with a mean postoperative period of 1 year.

CONCLUSIONS

The current study reported successful outcomes with very low complication rates after nonfusion surgery for patients with spinal metastases, even among those who survived for more than 6 months. More than half of the instrumentation-related complications were asymptomatic and did not require revision. The results suggest that nonfusion surgery might be sufficient for a majority of patients with spinal metastases.

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.

Relationship Between Visceral Metastases and Survival in Patients with Metastasis-related Spinal Cord Compression

OBJECTIVE

To investigate whether visceral metastases have a significant impact on survival in patients with metastasis-related spinal cord compression (MSCC), and to determine the difference in prognosis between patients with and without visceral metastases.

METHODS

Three institutional databases were searched to identify all patients who had undergone spinal surgery for spinal metastases between March 2002 and June 2010. Data on patient characteristics including pre- and post-operative medical conditions, were collected from medical records or by telephone follow-up. Survival data were obtained either from medical records or by searching a governmental cancer registry.

RESULTS

The mean age of study patients was 59.6 ± 10.5 years (range, 18-84 years), of whom 102 were male and 67 female. The median and mean postoperative survival times were 7.0 ± 0.5 (95% CI 6.0-8.0) months and 12.6 ± 1.2 (95% CI 10.1-15.0) months, respectively, in all patients, being 5.0 ± 0.5 (95% CI 4.0-6.0) months and 10.8 ± 2.4 (95% CI 6.1-15.5) months, respectively, for patients with visceral metastases and 7.0 ± 0.8 (95% CI 5.4-8.6) months and 13.0 ± 1.4 (95%CI 10.3-15.6) months, respectively, for patients without visceral metastases (P = 0.87). These survival times did not differ significantly between groups. Multivariate Cox proportional hazard regressions showed that visceral metastases had no statistically significant association with survival (P = 0.277), whereas rate of growth of primary tumor (P = 0.003), preoperative Karnofsky performance status (KPS) (P < 0.001), change in KPS (P < 0.001), and Frankel grade (P = 0.091) were independent prognostic factors in the whole cohort (P = 0.005). Changes in KPS (P = 0.001) and major complications (P = 0.003) were significantly associated with survival in patients with visceral metastases, whereas rate of growth of primary tumor (P = 0.016), change in KPS (P = 0.001), and preoperative KPS (P < 0.001) were significantly associated with survival in patients without visceral metastases.

CONCLUSIONS

Visceral metastases do not appear to predict the prognosis of patients with MSCC; thus, more aggressive surgery should be considered in patients with MSCC who have visceral metastases. Additionally, prognostic factors differ according to visceral metastases status in these patients.

Prognostic effect of factors involved in revised Tokuhashi score system for patients with spinal metastases: a systematic review and Meta-analysis

Background

Cancer patients’ survival time has obviously improved, with the development of systemic treatment techniques. However, the probability of metastases to the vertebrae has also been increased which makes some adverse effects on patients’ quality of life. The prediction of survival plays a key role in choosing therapeutic modality, and Tokuhashi Score was established as one of the most commonly used predictive systems for spinal metastases. Thus, this study was conducted to identify the prognostic effect of factors involved in revised Tokuhashi Score (RTS).

Methods

Two investigators independently retrieved relevant literature on platforms of PubMed, Embase and Cochrane Library. We identified eligible studies through title/abstract and full-text perusing. Data was extracted including general information of studies, participants’ characteristics, therapeutic modality, overall survival and prognostic effect of factors. Hazard ratio (HR) for each factor was synthesized if available through fixed- or random-effect models as appropriate.

Results

A total of 63 eligible studies with 10,411 participants were identified. Overall, cases with thyroid cancer had the highest survival rate, while the ones with non-small cell lung cancer and hepatocellular carcinoma lived for the shorted survival time. Performance status, bone metastasis, number of involved vertebrae, visceral metastasis, primary tumor and neurological status were regarded as significant predictors in 71.4, 40.0, 18.2, 63.4, 73.1 and 44.7% of the involved studies respectively. Thirty-eight articles were included in meta-analysis, and prognostic effects of five factors (apart from primary tumor) were analyzed. Factors were all proved to be significant except comparisons between KPS (Karnofsky Performance Status) 10–40 VS. 50–70 and single VS. multiple spinal metastases.

Conclusion

All factors of RTS were significant on prognosis predicting and should be considered when choosing therapeutic modality for spinal metastases. What’s more, we believe that more accurate prognosis may be obtained after removal of the cut-offs for KPS 10–40 VS. 50–70 and single VS. multiple involved vertebrae.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-5139-2) contains supplementary material, which is available to authorized users.

Survival Outcomes and Factors Associated with Revision Surgery for Metastatic Disease of the Spine

Study Design

Retrospective review of a prospective database.

Objective

Certain subset of patients undergoing surgical treatment for spinal metastasis will require a revision surgery in their disease course; however, factors predictive of revision surgery and survival outcomes are largely unknown. The goal of this study is to report on survival outcomes as well as factors predictive of revision surgery in this unique patient population.

Methods

A total of 55 patients who met the inclusion criteria were included from January 2010 to December 2015. Twelve (22%) of these patients underwent a revision surgery. Patient and tumor characteristics were summarized and survival outcomes were evaluated using Kaplan-Meier methods and Cox proportional hazards regression.

Results

Both the revision and the nonrevision groups were similarly matched with respect to spine disease burden, neurological status at time of initial presentation, primary malignancy types, and the use of adjuvant treatment modalities. Tumor progression (66.7%) was the most common reason for necessitating a revision followed by nonunion (16.7%), wound dehiscence (8.3%), and construct failure (8.3%). Following multivariate model selection procedures, smokers were found to have 3.5 times increased odds of undergoing revision compared to nonsmokers (p = 0.05). Analysis of survival curves showed that the median survival in the revision group was 3.0 years (95% CI: 1.5, 4.1), while the median survival in the nonrevision group was 1.5 years (95% CI: 1.1, 2.3; log-rank test, p = 0.105).

Conclusion

Despite aggressive treatment, tumor progression is the most common reason for revision surgery. Smoking is an independent risk factor for revision. Revision surgery should be considered in patients when indicated as it does not appear to detrimentally affect survival.

Natural History and Prognostic Factors of Cholangiocarcinoma With Spinal Metastasis: A 10-Year Single Center Study

STUDY DESIGN

This is a retrospective analysis.

OBJECTIVE

The aim of this study was to determine the epidemiology, survival, and prognostic factors for cholangiocarcinoma (CCA) with spinal metastasis.

SUMMARY OF BACKGROUND DATA

CCA is an epithelial cell malignancy of the bile duct, and a frequent site for its metastasis is the spine. Many areas of Asia are endemic for CCAs. To date, there is limited data on the epidemiology, natural history, and prognostic factors of CCA with spinal metastasis, which is crucial for better management and treatment of the disease.

MATERIALS AND METHODS

Patients diagnosed with CCA were recruited to our study, in order to identify cases with spinal metastasis. The survival rate was estimated by the Kaplan-Meier method. The univariate and multivariate analyses of tumor-specific and spinal metastatic factors were performed to identify the independent factors that affect survival.

RESULTS

From 2006 to 2015, 4585 CCA patients were identified and 182 of these patients had spinal metastasis. The overall median survival of patients with spinal metastasis was 88 days. Serum carcinoembryonic antigen <5 ng/mL, carbohydrate antigen 19-9 <39 U/mL, albumin ≥3.5 g/L, and Frankel score D-E were found to be independent factors that resulted in better survival in a multivariate Cox regression analysis. CCA resection or spinal surgery did not prolong the survival of patients with spinal metastasis.

CONCLUSION

Spinal surgery should be considered for CCA patients with spinal metastasis, who have a favorable prognosis, and are likely to live long enough to benefit from surgery. The aim is to palliate the symptoms and not as much to improve the survival.

Functional and survival outcomes in patients undergoing surgical treatment for metastatic disease of the spine

Background

Retrospective review of a prospective database. Spine metastasis has been shown to occur in 40% of cancer patients with an annual incidence of over 18,000 cases in North America alone. In this study, we sought to explore the functional and survival outcomes of patients undergoing surgical treatment for metastatic disease of the spine.

Methods

A retrospective cohort study of a prospective database at a major cancer center was conducted. A total of 55 patients who met the inclusion criteria from January 2010 to December 2015 were included. Functional status was assessed through patient's ambulatory status. Patient and tumor characteristics were analyzed and regression analyses were performed.

Results

Renal cell carcinoma (RCC) was the most common subtype encountered (27.3%). Excluding patients who had spinal metastasis at time of diagnosis, the median time to spinal metastasis from cancer diagnosis was 2.5 years. Median overall survival (OS) time was 1.8 years post diagnosis and 1.6 years post-surgical intervention. Age and tumor subtype were independent predictors of death (P<0.05). Post-surgical intervention, only 3.6% of patients were unable to ambulate-an improvement from 12.7% seen in the immediate preoperative period, P=0.0253. However, at the time of final follow-up, this number had risen to nearly 37%, P<0.0001.

Conclusions

Spinal metastasis portends a debilitating prognosis. Ambulatory status is improved or maintained in the post-surgical period. However, long-term outlook remains dismal with median survival at only 1.8 years following diagnosis of spinal metastasis and ambulatory status declining precipitously at the time of final follow-up.

Long-term follow-up of papillary and follicular thyroid carcinomas with bone metastasis

The aims of this study were to investigate papillary and follicular thyroid carcinomas with bone metastasis in various clinical presentations and to determine the prognostic factors after multimodality treatment. A retrospective analysis was performed of 3,120 patients with papillary and follicular thyroid carcinoma. Of these patients, 131 (including 97 women, 71.8%) were diagnosed with bone metastasis and underwent follow-up at the Chang Gung Medical Center. Patients with bone metastasis were categorized into two groups. Group A was comprised of patients who were diagnosed with bone metastasis either before thyroidectomy or within 6 months of the initial thyroidectomy (90 patients, 68.7%). Group B was comprised of patients with bone metastasis who received a diagnosis 6 months post-thyroidectomy in the follow-up period (41 patients, 31.3%). After a mean follow-up period of 8.4 ± 7.0 years, there were 88 deaths (67.2%) attributed to thyroid cancer and 13 patients (9.9%) achieved disease-free status. A multivariate analysis showed that older age, early diagnosis, and brain metastasis were each associated with a poor prognosis. The difference in disease-specific mortality rates between groups A and B was significant (p < 0.0001). In conclusion, papillary and follicular thyroid cancers with bone metastasis have a high rate of mortality. Despite this high mortality, 9.9% patients still had an excellent response to treatment.

Consensus guidelines for postoperative stereotactic body radiation therapy for spinal metastases: results of an international survey

OBJECTIVE Although postoperative stereotactic body radiation therapy (SBRT) for spinal metastases is increasingly performed, few guidelines exist for this application. The purpose of this study is to develop consensus guidelines to promote safe and effective treatment for patients with spinal metastases. METHODS Fifteen radiation oncologists and 5 neurosurgeons, representing 19 centers in 4 countries and having a collective experience of more than 1300 postoperative spine SBRT cases, completed a 19-question survey about postoperative spine SBRT practice. Responses were defined as follows: 1) consensus: selected by ≥ 75% of respondents; 2) predominant: selected by 50% of respondents or more; and 3) controversial: no single response selected by a majority of respondents. RESULTS Consensus treatment indications included: radioresistant primary, 1-2 levels of adjacent disease, and previous radiation therapy. Contraindications included: involvement of more than 3 contiguous vertebral bodies, ASIA Grade A status (complete spinal cord injury without preservation of motor or sensory function), and postoperative Bilsky Grade 3 residual (cord compression without any CSF around the cord). For treatment planning, co-registration of the preoperative MRI and postoperative T1-weighted MRI (with or without gadolinium) and delineation of the cord on the T2-weighted MRI (and/or CT myelogram in cases of significant hardware artifact) were predominant. Consensus GTV (gross tumor volume) was the postoperative residual tumor based on MRI. Predominant CTV (clinical tumor volume) practice was to include the postoperative bed defined as the entire extent of preoperative tumor, the relevant anatomical compartment and any residual disease. Consensus was achieved with respect to not including the surgical hardware and incision in the CTV. PTV (planning tumor volume) expansion was controversial, ranging from 0 to 2 mm. The spinal cord avoidance structure was predominantly the true cord. Circumferential treatment of the epidural space and margin for paraspinal extension was controversial. Prescription doses and spinal cord tolerances based on clinical scenario, neurological compromise, and prior overlapping treatments were controversial, but reasonable ranges are presented. Fifty percent of those surveyed practiced an integrated boost to areas of residual tumor and density override for hardware within the beam path. Acceptable PTV coverage was controversial, but consensus was achieved with respect to compromising coverage to meet cord constraint and fractionation to improve coverage while meeting cord constraint. CONCLUSIONS The consensus by spinal radiosurgery experts suggests that postoperative SBRT is indicated for radioresistant primary lesions, disease confined to 1-2 vertebral levels, and/or prior overlapping radiotherapy. The GTV is the postoperative residual tumor, and the CTV is the postoperative bed defined as the entire extent of preoperative tumor and anatomical compartment plus residual disease. Hardware and scar do not need to be included in CTV. While predominant agreement was reached about treatment planning and definition of organs at risk, future investigation will be critical in better understanding areas of controversy, including whether circumferential treatment of the epidural space is necessary, management of paraspinal extension, and the optimal dose fractionation schedules.

Consensus Contouring Guidelines for Postoperative Stereotactic Body Radiation Therapy for Metastatic Solid Tumor Malignancies to the Spine

PURPOSE

To develop consensus contouring guidelines for postoperative stereotactic body radiation therapy (SBRT) for spinal metastases.

METHODS AND MATERIALS

Ten spine SBRT specialists representing 10 international centers independently contoured the clinical target volume (CTV), planning target volume (PTV), spinal cord, and spinal cord planning organ at risk volume (PRV) for 10 representative clinical scenarios in postoperative spine SBRT for metastatic solid tumor malignancies. Contours were imported into the Computational Environment for Radiotherapy Research. Agreement between physicians was calculated with an expectation minimization algorithm using simultaneous truth and performance level estimation with κ statistics. Target volume definition guidelines were established by finding optimized confidence level consensus contours using histogram agreement analyses.

RESULTS

Nine expert radiation oncologists and 1 neurosurgeon completed contours for all 10 cases. The mean sensitivity and specificity were 0.79 (range, 0.71-0.89) and 0.94 (range, 0.90-0.99) for the CTV and 0.79 (range, 0.70-0.95) and 0.92 (range, 0.87-0.99) for the PTV), respectively. Mean κ agreement, which demonstrates the probability that contours agree by chance alone, was 0.58 (range, 0.43-0.70) for CTV and 0.58 (range, 0.37-0.76) for PTV (P<.001 for all cases). Optimized consensus contours were established for all patients with 80% confidence interval. Recommendations for CTV include treatment of the entire preoperative extent of bony and epidural disease, plus immediately adjacent bony anatomic compartments at risk of microscopic disease extension. In particular, a "donut-shaped" CTV was consistently applied in cases of preoperative circumferential epidural extension, regardless of extent of residual epidural extension. Otherwise more conformal anatomic-based CTVs were determined and described. Spinal instrumentation was consistently excluded from the CTV.

CONCLUSIONS

We provide consensus contouring guidelines for common scenarios in postoperative SBRT for spinal metastases. These consensus guidelines are subject to clinical validation.