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Morimoto T, Toda Y, Hakozaki M, Paholpak P, Watanabe K, Kato K, Tsukamoto M, Hirata H, Kaneuchi Y, Tome Y, Nagamine S, Nishida K, Katsuya H, Matsumoto Y, Otani K, Mawatari M, Nikaido T. A new era in the management of spinal metastasis. Front Oncol 2024; 14:1374915. [PMID: 38694784 PMCID: PMC11062132 DOI: 10.3389/fonc.2024.1374915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/02/2024] [Indexed: 05/04/2024] Open
Abstract
Despite the recent advances in cancer treatment, the incidence of patients with spinal metastases continues to grow along with the total number of cancer patients. Spinal metastases can significantly impair activities of daily living (ADL) and quality of life (QOL), compared with other types of bone metastases, as they are characterized with severe pain and paralysis caused by skeletal-related events. Reduced ADL can also lead to treatment limitations as certain anticancer agents and radiation therapy are not compatible treatments; thus, leading to a shorter life expectancy. Consequently, maintaining ADLs in patients with spinal metastases is paramount, and spine surgeons have an integral role to play in this regard. However, neurosurgeon, orthopedic and spinal surgeons in Japan do not have a proactive treatment approach to spinal metastases, which may prevent them from providing appropriate treatment when needed (clinical inertia). To overcome such endemic inertia, it is essential for 1) spine surgeons to understand and be more actively involved with patients with musculoskeletal disorders (cancer locomo) and cancer patients; 2) the adoption of a multidisciplinary approach (coordination and meetings not only with the attending oncologist but also with spine surgeons, radiologists, rehabilitation specialists, and other professionals) to preemptive treatment such as medication, radiotherapy, and surgical treatment; and 3) the integration of the latest findings associated with minimally invasive spinal treatments that have expanded the indications for treatment of spinal metastases and improved treatment outcomes. This heralds a new era in the management of spinal metastases.
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Affiliation(s)
- Tadatsugu Morimoto
- Department of Orthopedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Yu Toda
- Department of Orthopedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Michiyuki Hakozaki
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Permsak Paholpak
- Department of Orthopedics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Kazuyuki Watanabe
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Kinshi Kato
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Masatsugu Tsukamoto
- Department of Orthopedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Hirohito Hirata
- Department of Orthopedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Yoichi Kaneuchi
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yasunori Tome
- Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Satomi Nagamine
- Department of Orthopedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Kotaro Nishida
- Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Hiroo Katsuya
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Yoshihiro Matsumoto
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Koji Otani
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Masaaki Mawatari
- Department of Orthopedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Takuya Nikaido
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
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2
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El farissi MAA, Dehneh Y, Kada A, Dahamou M, Khoulali M, Oulali N, Moufid F. Uncommon spinal involvement of ALK-positive anaplastic large cell lymphoma: A pediatric case report and literature review. Radiol Case Rep 2024; 19:341-345. [PMID: 38028318 PMCID: PMC10663636 DOI: 10.1016/j.radcr.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 09/30/2023] [Accepted: 10/06/2023] [Indexed: 12/01/2023] Open
Abstract
Anaplastic large cell lymphoma (ALCL) is a rare variety of non-Hodgkin lymphoma that primarily affects children and young adults and is caused by the fusion of the nucleophosmin 1 and ALK genes, which turns on several signalling pathways. Despite the fact that ALCL frequently affects lymph nodes and extranodal sites, involvement of the central nervous system (CNS) is quite uncommon, with symptoms like pain and fever. The spinal localization may result in neurological impairments. T1WI hypointense lesions with T2WI hyperintensity can be observed on MR images, while bone sequestra can be seen in CT scans. The gold standard for diagnosis is still histology, though. Based on distinctive morphological characteristics, immunohistochemical staining can differentiate ALK-positive ALCL from other ALCLs. The prognosis for ALK-positive ALCL is typically better than ALK-negative ALCL, and treatment options include surgery followed by chemotherapy. ALK inhibitors and CAR-T cell therapy are 2 newly developed targeted treatments that have the potential to improve results. This case report illustrates the rarity of CNS ALCL and the difficulties in diagnosis and treatment by describing a 16-year-old female patient with ALCL affecting the thoracic spine and spreading to the mediastinum and surrounding tissue.
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Affiliation(s)
- Mohammed Al amine El farissi
- Department of Neurosurgery, Mohammed VI University Hospital, Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, Morocco
| | - Youness Dehneh
- Department of Neurosurgery, Mohammed VI University Hospital, Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, Morocco
| | - Amine Kada
- Department of Neurosurgery, Mohammed VI University Hospital, Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, Morocco
| | - Mohamed Dahamou
- Department of Neurosurgery, Mohammed VI University Hospital, Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, Morocco
| | - Mohamed Khoulali
- Department of Neurosurgery, Mohammed VI University Hospital, Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, Morocco
| | - Noureddine Oulali
- Department of Neurosurgery, Mohammed VI University Hospital, Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, Morocco
| | - Faycal Moufid
- Department of Neurosurgery, Mohammed VI University Hospital, Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, Morocco
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3
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Patel PP, Cao Y, Chen X, LeCompte MC, Kleinberg L, Khan M, McNutt T, Bydon A, Kebaish K, Theodore N, Larry Lo SF, Lee SH, Lubelski D, Redmond KJ. Oncologic and Functional Outcomes After Stereotactic Body Radiation Therapy for High-Grade Malignant Spinal Cord Compression. Adv Radiat Oncol 2024; 9:101327. [PMID: 38260225 PMCID: PMC10801652 DOI: 10.1016/j.adro.2023.101327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 07/21/2023] [Indexed: 01/24/2024] Open
Abstract
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.
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Affiliation(s)
- Palak P. Patel
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Yilin Cao
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Xuguang Chen
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Michael C. LeCompte
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Lawrence Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Majid Khan
- Department of Radiology, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania
| | - Todd McNutt
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | - Khaled Kebaish
- Orthopedic Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | - Sheng-fu Larry Lo
- Department of Neurosurgery, Zucker School of Medicine at Hoftstra, Manhasset, New York
| | - Sang H. Lee
- Orthopedic Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | - Kristin J. Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
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Park HY, Ha KY, Kim SI, Kim YS, Joh Y, Kim YH. When Should Spinal Surgery Be Considered for Spinal Metastasis from Non-Small Cell Lung Cancer?-Propensity Score Matched Study between Surgery with Radiotherapy and Radiotherapy Alone. J Clin Med 2023; 12:4683. [PMID: 37510797 PMCID: PMC10380908 DOI: 10.3390/jcm12144683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Background: Although metastatic spine disease is increasing, the debate on therapeutic modality remains due to the heterogeneity of tumors and patients. This study aims to evaluate the efficacies of surgery and risk factors for patients' survival from potentially unstable spinal metastasis of non-small cell lung cancer; (2) Methods: Twenty-two patients undergoing surgery and radiotherapy (group I) were compared with 22 patients undergoing radiotherapy alone (group II) using propensity score matching in a 1-to-1 format. Clinical outcomes included the performance status and ambulatory status. In addition, independent risk factors for patients' survival were evaluated, including the molecular targeted therapy for mutations; (3) Results: deterioration in neurologic status was only observed in group II compared to group I (22.7% vs. 0%, p-value = 0.018). In addition, five patients in the surgery group showed improved Frankel grades. Regarding the patients' survival, a smoking history of more than ten pack-years (hazard ratio (HR) = 12.18), worse performance status (HR = 6.86), and absence of mutations (HR = 3.39) were the independent risk factors; (4) Conclusions: Spinal surgery with radiotherapy could have advantages for improving the neurologic status including ambulation for potentially unstable spine due to metastasis. Thus, surgery should be considered for patients with a longer life expectancy resulting from better performance status and use of the targeted therapy.
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Affiliation(s)
- Hyung-Youl Park
- Department of Orthopaedic Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 03312, Republic of Korea
| | - Kee-Yong Ha
- Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea
| | - Sang-Il Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Yeon-Sil Kim
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Yongwon Joh
- Department of Orthopaedic Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 03312, Republic of Korea
| | - Young-Hoon Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
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5
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Cardia A, Cannizzaro D, Stefini R, Chibbaro S, Ganau M, Zaed I. The efficacy of laser interstitial thermal therapy in the management of spinal metastases: a systematic review of the literature. Neurol Sci 2023; 44:519-528. [PMID: 36181543 DOI: 10.1007/s10072-022-06432-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/27/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND In the last years, laser interstitial thermal therapy (LITT) has started to be used also in neurosurgical setting. Its efficacy for intracranial pathologies, namely, tumors and epilepsy, has been widely demonstrated. However, the literature evidences about the use of LITT for spinal lesions are recent, and it is still a topic of discussion regarding its efficacy. Here, the authors sought to present a systematic review of the literature investigating the utility of LITT for spinal lesions. METHODS Using PubMed, Scopus, and the Cochrane Library, the authors performed a systematic review of the literature focused on the use of spinal laser interstitial thermal therapy (sLITT). Included in the search were randomized controlled trials, cohort studies, and clinical series. Two independent reviewers conducted the study appraisal, data abstraction, and quality assessments of the studies. RESULTS Out of the initial 134 studies, 6 met the inclusion criteria for the systematic review, resulting in a total of 206 patients. All the patients have been treated with sLITT for compressive spinal metastases. Most of the lesions were thoracic (88.8%). All the studies reported an effective local control of the disease with a reduction of epidural compression at 30 days. Complication rate was 12.6%, but most of them were transient conditions, and only 3.4% patients needed a revision surgery. CONCLUSION sLITT is safe and provides effective local control for epidural compression from metastases, particularly in the thoracic spine. The authors propose considering sLITT as an alternative to open surgery in selected patients with spinal metastases.
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Affiliation(s)
- Andrea Cardia
- Department of Neurosurgery, Neurocenter of South Switzerland, EOC, Lugano, Switzerland
| | - Delia Cannizzaro
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Department of Neurosurgery, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Roberto Stefini
- Department of Neurosurgery, Azienda Socio Sanitaria Territoriale (ASST) Ovest Milanese - Legnano Hospital, Milan, Italy
| | - Salvatore Chibbaro
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Mario Ganau
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ismail Zaed
- Department of Neurosurgery, Neurocenter of South Switzerland, EOC, Lugano, Switzerland. .,Department of Neurosurgery, Legnano Hospital, Legnano, Italy.
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Kim H, Kim D, Kim S. Primary Malignant Lymphoma Presenting as an Isolated Epidural Mass. Diagnostics (Basel) 2022; 12:diagnostics12102462. [PMID: 36292151 PMCID: PMC9600437 DOI: 10.3390/diagnostics12102462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 09/29/2022] [Accepted: 10/03/2022] [Indexed: 11/16/2022] Open
Abstract
Primary central nervous system lymphoma is a rare form of extranodal non-Hodgkin’s lymphoma that occurs in the brain, spinal cord, leptomeninges, or eyes and typically remains confined to the central nervous system. Among them, malignant lymphoma presenting as a primary tumor of the spinal cord is extremely uncommon, and epidural mass formation is known to occur in only 0.8–2.8% of cases of malignant lymphomas. Furthermore, primary malignant lymphoma presenting as an isolated epidural mass is much rarer. Here, we report a case of primary malignant lymphoma of the thoracic spine presenting as an isolated epidural mass that did not involve the vertebral body or posterior element. Surgical decompression is essential to prevent further neurological deterioration. Here, we present a successful treatment strategy for this rare case.
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Affiliation(s)
| | | | - Seokwon Kim
- Correspondence: ; Tel.: +82-62-220-3126; Fax: +82-62-227-4575
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Yano N, Ono T, Suzuki T, Sugai Y, Yamada M, Kawashiro S, Harada M, Akamatsu H, Hagiwara Y, Ichikawa M, Sato H, Takagi M, Kanoto M, Nemoto K. MRI Grading Scale Predicts Ambulatory Function After Radiotherapy for Metastatic Spinal Cord Compression: A Prospective Single-Institution Observational Study. Oncol Ther 2022; 10:493-501. [PMID: 35852785 PMCID: PMC9681941 DOI: 10.1007/s40487-022-00204-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/01/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Although magnetic resonance imaging (MRI) is an important modality for the diagnosis of metastatic spinal cord compression (MSCC), there are only a few reports on MSCC findings and symptoms after radiotherapy. We aimed to reveal the factors related to ambulatory function after treatment, including the MRI findings, in a prospective observational study. Methods Patients with suspected MSCC who were treated with radiotherapy were included in this study. Orthopedic surgeons evaluated the neurological function according to the Frankel grade. All patients underwent spinal MRI, and the degree of spinal cord compression was assessed by a radiologist and a radiation oncologist using an MRI grading scale. One month after treatment, orthopedic surgeons reassessed the Frankel grade. Twenty-three patients who were evaluated 1 month after radiotherapy were included in the analysis. Results Before radiotherapy, 17 patients were ambulatory and six were unable to walk. Furthermore, 13 patients were diagnosed with grade 3 compression on MRI (spinal cord compression with no cerebrospinal fluid seen on axial T2-weighted imaging). Patients with grade 3 MSCC were significantly more likely to be non-ambulatory at 1 month. Conclusions The MRI grading scale for MSCC may be a prognostic factor for ambulatory function after radiotherapy. MRI findings could aid in determining the indication for radiotherapy.
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Affiliation(s)
- Natsuko Yano
- Department of Radiology, Division of Radiation Oncology, Yamagata University Faculty of Medicine, Yamagata, 990-9585, Japan.
| | - Takashi Ono
- Department of Radiology, Division of Radiation Oncology, Yamagata University Faculty of Medicine, Yamagata, 990-9585, Japan
| | - Tomoto Suzuki
- Department of Orthopaedics, Yamagata University Faculty of Medicine, Yamagata, 990-9585, Japan
| | - Yasuhiro Sugai
- Department of Radiology, Division of Diagnostic Radiology, Yamagata University Faculty of Medicine, Yamagata, 990-9585, Japan
| | - Masayoshi Yamada
- Department of Radiology, Division of Radiation Oncology, Yamagata University Faculty of Medicine, Yamagata, 990-9585, Japan
| | - Shohei Kawashiro
- Department of Radiology, Division of Radiation Oncology, Yamagata University Faculty of Medicine, Yamagata, 990-9585, Japan
| | - Mayumi Harada
- Department of Radiology, Division of Radiation Oncology, Yamagata University Faculty of Medicine, Yamagata, 990-9585, Japan
| | - Hiroko Akamatsu
- Department of Radiology, Division of Radiation Oncology, Yamagata University Faculty of Medicine, Yamagata, 990-9585, Japan
| | - Yasuhito Hagiwara
- Department of Radiology, Division of Radiation Oncology, Yamagata University Faculty of Medicine, Yamagata, 990-9585, Japan
| | - Mayumi Ichikawa
- Department of Radiology, Division of Radiation Oncology, Yamagata University Faculty of Medicine, Yamagata, 990-9585, Japan
| | - Hiraku Sato
- Department of Radiology, Division of Radiation Oncology, Yamagata University Faculty of Medicine, Yamagata, 990-9585, Japan
| | - Michiaki Takagi
- Department of Orthopaedics, Yamagata University Faculty of Medicine, Yamagata, 990-9585, Japan
| | - Masafumi Kanoto
- Department of Radiology, Division of Diagnostic Radiology, Yamagata University Faculty of Medicine, Yamagata, 990-9585, Japan
| | - Kenji Nemoto
- Department of Radiology, Division of Radiation Oncology, Yamagata University Faculty of Medicine, Yamagata, 990-9585, Japan
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ESTRO ACROP guidelines for external beam radiotherapy of patients with complicated bone metastases. Radiother Oncol 2022; 173:240-253. [DOI: 10.1016/j.radonc.2022.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 05/31/2022] [Accepted: 06/01/2022] [Indexed: 12/19/2022]
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9
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Li RF, Qiao RQ, Xu MY, Ma RX, Hu YC. Separation Surgery in the Treatment of Spinal Metastasis. Technol Cancer Res Treat 2022; 21:15330338221107208. [PMID: 35702739 PMCID: PMC9208034 DOI: 10.1177/15330338221107208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Rui-Feng Li
- Department of Bone and Soft Tissue Oncology, 74768Tianjin Hospital, Tianjin, China.,Graduate School, 12610Tianjin Medical University, Tianjin, China
| | - Rui-Qi Qiao
- Department of Bone and Soft Tissue Oncology, 74768Tianjin Hospital, Tianjin, China.,Graduate School, 12610Tianjin Medical University, Tianjin, China
| | - Ming-You Xu
- Department of Bone and Soft Tissue Oncology, 74768Tianjin Hospital, Tianjin, China.,Graduate School, 12610Tianjin Medical University, Tianjin, China
| | - Rong-Xing Ma
- Department of Bone and Soft Tissue Oncology, 74768Tianjin Hospital, Tianjin, China.,Graduate School, 12610Tianjin Medical University, Tianjin, China
| | - Yong-Cheng Hu
- Department of Bone and Soft Tissue Oncology, 74768Tianjin Hospital, Tianjin, China
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10
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Chi JE, Ho CY, Chiu PY, Kao FC, Tsai TT, Lai PL, Niu CC. Minimal invasive fixation following with radiotherapy for radiosensitive unstable metastatic spine. Biomed J 2021; 45:717-726. [PMID: 34450348 PMCID: PMC9486178 DOI: 10.1016/j.bj.2021.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 06/29/2021] [Accepted: 08/19/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Minimally invasive surgery (MIS) has become a feasible option for patients with spinal metastasis, but the effectiveness of percutaneous pedicle screw fixation (PPSF) without decompression in patients with severe cord compression remains unknown. We compared PPSF without decompression with debulking surgery in patients with radiosensitive, unstable, metastatic thoracolumbar spinal cord compression. METHODS A retrospective study of surgically treated spinal metastasis and spinal cord compression patients was conducted between October 2014 and June 2019. Demographic and pre- and postoperative data were collected and compared between patients treated with minimally invasive percutaneous fixation and external beam radiotherapy (EBRT) (the PPSF group) and those treated with debulking surgery (the debulking group). RESULTS We included 50 patients in this study. The PPSF group had a significantly shorter operative time (143.56 ± 49.44 min vs. 181.47 ± 40.77 min; p < .01), significantly lower blood loss (116.67 ± 109.92 mL vs. 696.55 ± 519.43 mL; p < .01), and significantly shorter hospital stay (11.90 ± 9.69 vs. 25.35 ± 20.65; p <0.01) than did the debulking group. No significant differences were observed between the groups in age, sex, spinal instability neoplastic score, ESCC, Tomita scores, numeric rating scale scores, American Spinal Injury Association Impairment Scale scores, survival rates, and complication rates. Postoperative neurologic function and decrease in pain were similar between the groups. CONCLUSION The PPSF group had a shorter operation time, shorter length of hospital stay, and less blood loss than did the debulking group. PPSF followed by EBRT is pain relieving, relatively safe and appropriate as palliative therapy.
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Affiliation(s)
- Jia-En Chi
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chun-Yee Ho
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ping-Yeh Chiu
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Fu-Cheng Kao
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Tsung-Ting Tsai
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan.
| | - Po-Liang Lai
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chi-Chien Niu
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
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11
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Xu W, Yang M, Zhao C, Wang P, Deng K, Yang X, Wei H, Xiao J. Massive Spondylectomy for Metastatic Spinal Cord Compression From Non-Small-Cell Lung Cancer With Local Failure After Radiotherapy. Global Spine J 2021; 11:549-555. [PMID: 32875923 PMCID: PMC8119919 DOI: 10.1177/2192568220919099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
STUDY DESIGN. A retrospective multivariate analysis. OBJECTIVE. To analyze clinical outcomes of surgical treatment and prognostic factors of local failure after stereotactic body radiation therapy (SBRT) in patients with spinal metastatic non-small-cell lung cancer (NSCLC). METHODS. This study included patients with metastatic spinal cord compression (MSCC) from spinal NSCLC after radiotherapy who received massive spondylectomy for circumferential decompression of spinal cord and reconstruction of spinal stability in our center between May 2006 and February 2017. Neurological function was evaluated using the Frankel score. Overall survival (OS) was estimated by the Kaplan-Meier method. Factors with Pvalues ≤.1 were subjected to multivariate analysis for OS by proportional hazard analysis. Values of P<.05 were considered statistically significant. RESULTS. The mean age of the 55 included patients (36 male and 19 female) was 57.76 ± 8.94 (median 58, range 36-77) years, with a mean postoperative OS of 14.98 ± 14.81 (median 10.0, range 1-84) months. Neurological function was improved in 46 (83.6%) of the 55 patients after surgery. Prognostic analysis suggested that preoperative frankel score (FS) score, visceral metastasis, D-dimer (D-D) level, and neutrophil/lymphocyte ratio (NLR) were independent prognostic factors for selected patients. CONCLUSIONS. Massive spondylectomy could provide circumferential decompression and improve the neurological function of patients with MSCC from spinal NSCLC after radiotherapy. A preoperative FS score of C/D, no visceral metastasis, D-D <1000 μg/L, and NLR <5 are predictors of better prognosis.
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Affiliation(s)
- Wei Xu
- Second Military Medical University, Shanghai, China
| | - Minglei Yang
- Second Military Medical University, Shanghai, China
| | | | - Peng Wang
- Second Military Medical University, Shanghai, China
| | - Kan Deng
- No. 455 Hospital of PLA, Shanghai, China
| | - Xinghai Yang
- Second Military Medical University, Shanghai, China
| | - Haifeng Wei
- Second Military Medical University, Shanghai, China
| | - Jianru Xiao
- Second Military Medical University, Shanghai, China,Jianru Xiao, Department of Orthopedic
Oncology, Changzheng Hospital, Second Military Medical University, 415 Fengyang
Road, Shanghai, 200003, China.
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12
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An Overview of Decision Making in the Management of Metastatic Spinal Tumors. Indian J Orthop 2021; 55:799-814. [PMID: 34194637 PMCID: PMC8192670 DOI: 10.1007/s43465-021-00368-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 01/29/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Spinal metastases are the most commonly encountered spinal tumors. With increasing life expectancy and better systemic treatment options, the incidence of patients seeking treatment for spinal metastasis is rising. Radical resections and conventional low-dose radiotherapy have given way to modern 'separation' surgeries and stereotactic body radiotherapy which entails lesser morbidity and improved local control. This article provides an overview of the decision making and currently available treatment options for metastatic spinal tumors. METHODS A MEDLINE literature search was made for studies in English language reporting on human subjects, describing results of various treatment options that are a part of multidisciplinary management of metastatic spinal tumors. The highest-quality evidence available in the literature was reviewed. DISCUSSION Treatment of patients with metastatic spinal tumors is largely palliative, with radiotherapy and selective surgery being the mainstays of management. Multidisciplinary management that incorporates factors like patient performance status, expected survival and systemic burden of disease and employs well-validated decision-making frameworks for guiding treatment holds the key to an effective palliative treatment strategy. Effective pain management, achieving local control, adequate neurological decompression in the setting of epidural cord compression and surgical stabilization for mechanical stabilization are the main goals of treatment. CONCLUSION The management of metastatic spinal tumors has been rapidly evolving; currently, limited decompression and stabilization followed by postoperative SBRT for local tumor control are associated with less morbidity and may be referred to as the current standard of care in these patients.
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Chen B, Cai L, Zhou F. Management of acute spinal cord compression in multiple myeloma. Crit Rev Oncol Hematol 2020; 160:103205. [PMID: 33387626 DOI: 10.1016/j.critrevonc.2020.103205] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 09/04/2020] [Accepted: 12/20/2020] [Indexed: 11/15/2022] Open
Abstract
Spinal cord compression (SCC) is a devastating complication of multiple myeloma and has the potential to cause loss of neurological function. The common symptoms of SCC are back pain, motor weakness, and sensory change. Once diagnosed, the patient should be managed as soon as possible to prevent permanent loss of neurological function. Currently, there have been a number of studies describing the mechanism and management experience of SCC in patients with myeloma. The clinical features, diagnostic strategies, and the roles of different therapeutic options are herein reviewed.
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Affiliation(s)
- Bo Chen
- Department of Hematology, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, China
| | - Lin Cai
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Fuling Zhou
- Department of Hematology, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, China.
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Kumar N, Madhu S, Bohra H, Pandita N, Wang SSY, Lopez KG, Tan JH, Vellayappan BA. Is there an optimal timing between radiotherapy and surgery to reduce wound complications in metastatic spine disease? A systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:3080-3115. [DOI: 10.1007/s00586-020-06478-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/25/2020] [Indexed: 12/13/2022]
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How good are the outcomes of instrumented debulking operations for symptomatic spinal metastases and how long do they stand? A subgroup analysis in the global spine tumor study group database. Acta Neurochir (Wien) 2020; 162:943-950. [PMID: 31953690 DOI: 10.1007/s00701-019-04197-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 12/23/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The benefits of surgery for symptomatic spinal metastases have been demonstrated, largely based on series of patients undergoing debulking and instrumentation operations. However, as cancer treatments improve and overall survival lengths increase, the incidence of recurrent spinal cord compression after debulking may increase. The aim of the current paper is to document the postoperative evolution of neurological function, pain, and quality of life following debulking and instrumentation in the Global Spine Tumor Study Group (GSTSG) database. METHODS The GSTSG database is a prospective multicenter data repository of consecutive patients that underwent surgery for a symptomatic spinal metastasis. For the present analysis, patients were selected from the database that underwent decompressive debulking surgery with instrumentation. Preoperative tumor type, Tomita and Tokuhashi scores, EQ-5D, Frankel, Karnofsky, and postoperative complications, survival, EQ-5D, Frankel, Karnofsky, and pain numeric rating scores (NRS) at 3, 6, 12, and 24 months were analyzed. RESULTS A total of 914 patients underwent decompressive debulking surgery with instrumentation and had documented follow-up until death or until 2 years post surgery. Median preoperative Karnofsky performance index was 70. A total of 656 patients (71.8%) had visceral metastases and 490 (53.6%) had extraspinal bone metastases. Tomita scores were evenly distributed above (49.1%) and below or equal to 5 (50.9%), and Tokuhashi scores almost evenly distributed below or equal to 8 (46.3%) and above 8 (53.7%). Overall, 12-month survival after surgery was 56.3%. The surgery resulted in EQ-5D health status improvement and NRS pain reduction that was maintained throughout follow-up. Frankel scores improved at first follow-up in 25.0% of patients, but by 12 months neurological deterioration was observed in 18.8%. CONCLUSION We found that palliative debulking and instrumentation surgeries were performed throughout all Tomita and Tokuhashi categories. These surgeries reduced pain scores and improved quality of life up to 2 years after surgery. After initial improvement, a proportion of patients experienced neurological deterioration by 1 year, but the majority of patients remained stable.
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16
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Laratta JL, Weegens R, Malone KT, Chou D, Smith WD. Minimally invasive lateral approaches for the treatment of spinal tumors: single-position surgery without the "flip". JOURNAL OF SPINE SURGERY 2020; 6:62-71. [PMID: 32309646 DOI: 10.21037/jss.2019.12.12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Although primary tumors of the spine and neural elements are rare, metastatic disease to the spine is quite common. Traditionally, surgical treatment for spinal tumor patients involves open decompression with or without stabilization. The single-position minimally invasive (MIS) lateral approach, which has been recently described over the recent decade, allows simultaneous access to the anterior and posterior columns with the patient positioned in the lateral decubitus position. Herein, we review the application of single-position MIS lateral surgery for the treatment of spinal neoplasm. The aim was to review the evolution, operative technique, outcomes, and complications associated with MIS lateral approaches for spinal tumors. The history of spinal tumor diagnosis and management are reviewed and discussed as well as the author's experience and literature regarding spinal tumor treatment outcome and surgical complications, with particular attention to single-position, MIS lateral approaches. In addition, the author's surgical technique is outlined in detail for thoracic, thoracolumbar and lumbar tumors. Furthermore, there are specific indications and complications associated with the surgical treatment of spinal tumors, and the MIS, single-position lateral approach, when applied appropriately, allows for concurrent access to the anterior and posterior column while mitigating the complications associated with traditional, open posterior-based approaches. In the treatment of spinal neoplasms, the goals of surgery are dictated by a number of tumor-specific and patient-specific factors. Therefore, operative treatment of tumors in the future may be a consolidation of historical surgical techniques and MIS, single-position lateral approaches. Regardless, multidisciplinary management is imperative for the individualized treatment of the patient and optimization of outcome.
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Affiliation(s)
- Joseph L Laratta
- Norton Leatherman Spine Center, Louisville, KY, USA.,University of Louisville Medical Center, Louisville, KY, USA
| | - Ryan Weegens
- University of Louisville Medical Center, Louisville, KY, USA
| | - Kyle T Malone
- Clinical Resources, NuVasive, Inc., San Diego, CA, USA
| | - Dean Chou
- University of California San Francisco, San Francisco, CA, USA
| | - William D Smith
- Western Regional Center for Brain and Spine Surgery, Las Vegas, NV, USA.,University Medical Center of Southern Nevada, Las Vegas, NV, USA
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Delgado-López PD, Roldán-Delgado H, Corrales-García EM. Stereotactic body radiation therapy and minimally invasive surgery in the management of spinal metastases: a change in the paradigm. Neurocirugia (Astur) 2019; 31:119-131. [PMID: 31668627 DOI: 10.1016/j.neucir.2019.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/26/2019] [Accepted: 08/26/2019] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
| | - Héctor Roldán-Delgado
- Servicio de Neurocirugía, Complejo Hospitalario Universitario de Canarias, Tenerife, España
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18
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Meenakshisundaram N, Dhandapani B. Giant Spinal Intradural Metastatic Adenocarcinoma of Unknown Primary: A Rare Case Report. Asian J Neurosurg 2019; 14:949-951. [PMID: 31497137 PMCID: PMC6703058 DOI: 10.4103/ajns.ajns_65_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Giant intradural metastases of nonneurogenic origin involving multiple segments represent an extremely rare manifestation of an unknown primary. The respective literature is very scarce. We present a 45-year-old female with complaints of low back pain for 4 years, involuntary urination for 2 years, and difficulty in using both lower limbs for 1 month. Examination revealed paraparesis with hypotonia. Imaging of lumbosacral spine revealed that expansile lytic destruction of vertebral bodies and posterior elements was noted from D8 to S2 vertebra and a large-sized patchy enhancing heterogeneous intradural extramedullary lesion was noted in D8–S2 level. Decompressive laminectomy from D11 to L4 vertebra and subtotal excision of the lesion were done. There was a marked improvement in the lower limb weakness and low back pain postoperatively. Histopathology revealed metastatic adenocarcinoma. Immunohistochemistry showed epithelial membrane antigen positivity. Accordingly, the aim of the surgery is strictly palliative. The majority of patients benefit with respect to neurological deficit/pain independent of the extent of resection. Thus, decompressive surgery is recommended to increase the quality of life. The occurrence of intradural spinal metastasis is rare. Only few cases of intra dural spinal metastasis involving multiple cord segments and osteolytic bony erosions have been documented. Hence this case is being presented here for its rarity and its uniqueness.
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Affiliation(s)
| | - Balasubramanian Dhandapani
- Department of Neurosurgery, Institute of Neurosurgery, Madras Medical College, Chennai, Tamil Nadu, India
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19
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Yang XG, Feng JT, Wang F, He X, Zhang H, Yang L, Zhang HR, Hu YC. Development and validation of a prognostic nomogram for the overall survival of patients living with spinal metastases. J Neurooncol 2019; 145:167-176. [DOI: 10.1007/s11060-019-03284-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/31/2019] [Indexed: 11/29/2022]
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20
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Tsagozis P, Bauer HCF. Outcome of Surgical Treatment for Spinal Cord Compression in Patients With Hematological Malignancy. Int J Spine Surg 2019; 13:186-191. [PMID: 31131219 DOI: 10.14444/6025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background We investigated the outcome of surgical treatment of patients with radiosensitive hematological malignancies presenting with spinal cord compression. Methods Retrospective review of 50 patients who had treatment between 1993 and 2012. Results The neurological outcome was favorable in 35 patients, stable in 12, whereas 3 patients deteriorated. Decompression within 48 hours from referral was associated with a superior neurological recovery (P = .001). Complications were noted in 11 patients, and 6 of these underwent secondary surgery. Early (30-day) mortality was 8%. Radiotherapy was associated with increased incidence of complications (χ2 = 0.009). Patients who had low blood hemoglobin preoperatively as well as those who remained totally bedridden postoperatively had an inferior overall survival rate (P < .001). Conclusion Patients with cord compression from hematological malignancy benefit from early surgical decompression. There is an inherent high risk for complications, which increases further if radiotherapy is given. Patients failing to ambulate after surgery have a poor prognosis.
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Affiliation(s)
- Panagiotis Tsagozis
- Department of Orthopaedic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik C F Bauer
- Department of Orthopaedic Surgery, Karolinska University Hospital, Stockholm, Sweden
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21
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Fridley J, Gokaslan ZL. The evolution of surgical management for vertebral column tumors. J Neurosurg Spine 2019; 30:417-423. [PMID: 30933909 DOI: 10.3171/2018.12.spine18708] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 12/14/2018] [Indexed: 11/06/2022]
Abstract
In BriefThere has been a significant shift in treatment paradigms for both primary and metastatic spine tumors over the last several decades. This article highlights some of the more important treatment advances that practitioners should be made aware of. It is important to not only incorporate these changes into individual practice but also appreciate the treatment trends that herald a significantly different future for spine tumor treatment.
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22
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Levin AS, Alcorn SR, Neuman BJ, Meyer CF. Team Approach: Emergencies in Patients with Skeletal Metastases. JBJS Rev 2019; 7:e8. [PMID: 30920480 DOI: 10.2106/jbjs.rvw.18.00036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Adam S Levin
- Department of Orthopaedic Surgery (A.S.L. and B.J.N.), Department of Radiation and Molecular Radiation Sciences (S.R.A.), Sidney Kimmel Comprehensive Cancer Center (C.F.M.), The Johns Hopkins School of Medicine, Baltimore, Maryland
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Abstract
Due to a worldwide increase of cancer incidence and a longer life expectancy of patients with metastatic cancer, a rise in the incidence of symptomatic vertebral metastases has been observed. Metastatic spinal disease is one of the most dreaded complications of cancer as it is not only associated with severe pain, but also with paralysis, sensory loss, sexual dysfunction, urinary and fecal incontinency when the neurologic elements are compressed. Rapid diagnosis and treatment have been shown to improve both the quality and length of remaining life. This chapter on vertebral metastases with epidural disease and intramedullary spinal metastases will be discussed in terms of epidemiology, pathophysiology, demographics, clinical presentation, diagnosis, and management. With respect to treatment options, our review will summarize the evolution of conventional palliative radiation to modern stereotactic body radiotherapy for spinal metastases and the surgical evolution from traditional open procedures to minimally invasive spine surgery. Lastly, we will review the most common clinical prediction and decision rules, framework and algorithms, and guidelines that have been developed to guide treatment decision making.
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Vellayappan BA, Chao ST, Foote M, Guckenberger M, Redmond KJ, Chang EL, Mayr NA, Sahgal A, Lo SS. The evolution and rise of stereotactic body radiotherapy (SBRT) for spinal metastases. Expert Rev Anticancer Ther 2018; 18:887-900. [DOI: 10.1080/14737140.2018.1493381] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Balamurugan A. Vellayappan
- Department of Radiation Oncology, National University Cancer Institute Singapore, National University Health System, Singapore
| | - Samuel T. Chao
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Kristin J. Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University, Baltimore, MD, USA
| | - Eric L. Chang
- Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Nina A. Mayr
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Simon S. Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
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Vellayappan BA, Kumar N, Chang EL, Sahgal A, Sloan AE, Lo SS. Novel multidisciplinary approaches in the management of metastatic epidural spinal cord compression. Future Oncol 2018; 14:1665-1668. [PMID: 29939082 DOI: 10.2217/fon-2018-0133] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Balamurugan A Vellayappan
- Department of Radiation Oncology, National University Cancer Institute, National University Health System, Singapore 119228
| | - Naresh Kumar
- Department of Orthopaedic Surgery, National University Health System, Singapore 119228
| | - Eric L Chang
- Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, CA 90089, USA
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Andrew E Sloan
- Department of Neurological Surgery, Seidman Cancer Center & University Hospitals - Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA 98195, USA
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Dalle Ore CL, Ames CP, Magill ST, Deviren V, Aghi MK, Lau D. Initial Experience with Intraoperative Phosphorous-32 Brachytherapy During Resection of Malignant Spinal Tumors. World Neurosurg 2018; 115:e785-e793. [PMID: 29702311 DOI: 10.1016/j.wneu.2018.04.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/14/2018] [Accepted: 04/16/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Brachytherapy is a major adjuvant modality for neoplasms, but few have trialed its use for spinal tumors. This study examines perioperative and oncologic outcomes of patients with malignant spinal tumors who underwent resection with intraoperative phosphorous-32 (P32) brachytherapy. METHODS Consecutive adult patients who underwent P32 brachytherapy during malignant spinal tumor resection were retrospectively identified from 2014 to 2015. Complications, tumor recurrence, and survival were reviewed. A comprehensive review of the literature was performed. RESULTS A total of 8 patients were included. Average age was 54.3 years, and 25.0% were males. Tumor types included metastatic leiomyosarcoma, chordoma, multifocal recurrent ependymomas, breast metastasis, malignant meningioma, and myxofibrosarcoma. One-half of patients underwent en bloc tumor resection. P32 plaques were applied to 2 sites per patient for mean 13.1 minutes per site with a goal penetration of 10 Gy to 1-mm depth. Perioperative complications occurred in 3 patients (37.5%), including a persistent cerebral spinal fluid leak, deep infection requiring reoperation, and sacral insufficiency fracture. At a mean 25.6 months follow-up, local recurrence rate was 25.0%, and overall survival was 75.0%. Mean time to recurrence was 14.4 months. Survival at 6, 12, 18, and 24 months was 100.0%, 100.0%, 85.7%, and 71.4%, respectively. CONCLUSIONS The use of P32 is safe and feasible. P32 intraoperative brachytherapy does not seem to increase the rate of complications. The sample size of this series is small with heterogeneity in tumor type, but recurrence and survival outcomes seem promising compared with previous reports. Further clinical trials are needed.
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Affiliation(s)
- Cecilia L Dalle Ore
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Stephen T Magill
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Vedat Deviren
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Manish K Aghi
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Darryl Lau
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
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Maranzano E, Trippa F, Chirico L, Basagni ML, Rossi R. Management of Metastatic Spinal Cord Compression. TUMORI JOURNAL 2018; 89:469-75. [PMID: 14870766 DOI: 10.1177/030089160308900502] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Metastatic spinal cord compression, diagnosed in 3–7% of cancer patients, is one of the most dreaded complications of metastatic cancer. It is an oncologic emergency, which must be diagnosed early and treated promptly to achieve the best results and avoid progressive pain, paralysis, sensory loss and sphincter incontinence. Patients who are ambulatory at the time of the diagnosis have a higher probability of obtaining good response to treatment and a longer survival. In clinical practice, back pain accompanies metastatic spinal cord compression in most cases, even in patients with no neurologic deficits. Magnetic resonance imaging is the best tool for diagnosing metastatic spinal cord compression and is able to identify spinal cord compression in 32–35% patients with back pain, bone metastases and normal neurologic examination. Moreover, magnetic resonance imaging gives the extension of the lesion, can diagnose other unsuspected clinical metastatic spinal cord compression sites, and is useful for the radiation oncologist in defining the target volume. Radiotherapy is the treatment of choice in most cases, whereas surgery is advised only in selected patients (ie, if stabilization is necessary, if radiotherapy has already been given in the same area, when vertebral body collapse causes bone impingement on the cord or nerve roots, when there are diagnostic doubts, or when computed tomography-guided percutaneous vertebral biopsy cannot be performed). Laminectomy should be abandoned in favor of more aggressive surgery (ie, posterior, anterior, and/or lateral approach, tumor mass resection, and stabilization of the spine). Generally, radiotherapy must be administered 7–10 days after surgery. The optimal radiation schedule has not been defined. However, as recently suggested by some clinical trials, even the hypofractionated radiotherapy regimens are effective and can be used without increasing radiation-induced myelopathy. Moderate doses of dexamethasone should be used in the early phases of therapy. After radiotherapy, spinal recurrence is generally found in sites different from the first compression area. A close post-treatment follow-up is suggested using clinical parameters (pain, motor and sphincter function), and magnetic resonance imaging should be performed only when a second metastatic spinal cord compression and/or myelopathy are clinically suspected.
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Maranzano E, Latini P, Beneventi S, Marafioti L, Piro F, Perrucci E, Lupattelli M. Comparison of two Different Radiotherapy Schedules for Spinal Cord Compression in Prostate Cancer. TUMORI JOURNAL 2018; 84:472-7. [PMID: 9824999 DOI: 10.1177/030089169808400407] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and background To assess the clinical outcome and toxicity of two different radiotherapy (RT) schedules for the management of metastatic spinal cord compression from prostate cancer, we performed a prospective analysis of 44 patients with the complication. Methods Two different RT schedules were adopted, a split-course regimen of 5 Gy x 3, 4 days rest, and then 3 Gy x 5, and a short-course regimen of 8 Gy, 7 days rest, and then 8 Gy. The split-course RT was adopted for all prostate cancer patients referred to our center between 1986 and 1992. Starting in 1993, the short-course RT was added for patients with a poor prognosis (i.e., paresis or paraplegia, low performance status, and/or short life expectation), whereas others still underwent the split-course regimen. So, 27 (61%) patients were treated with the split-course and the other 17 (39%) with the short-course regimen. Medium follow-up was 48 months (range, 6 to 123). Results Back pain total response rate was 82%. Effectiveness of RT on motor and bladder capacity was conditioned by pretreatment status of patients. All 20 (100%) walking cases maintained the function, whereas 11 of 24 (46%) with motor impairment regained the ability. The difference in response rate was statistically significant (P<0.001). All 36 (100%) patients, able to void at presentation preserved the capacity, whereas 3 of 8 (38%) with sphincter dysfunction no longer needed an indwelling catheter. Posttreatment neurologic status was the only factor found to affect survival. Median survival, 9 months for the whole group, was 10 and 2 months for posttreatment walking and nonwalking patients, respectively (10 vs 2 months, P<0.001). Neither presence of other metastases nor RT regimen used (split vs short-course) conditioned response rate, duration of response or survival. Acute or late, severe toxicity was never recorded. No patient complained of spinal cord morbidity. Conclusions Both split-course and short-course RT schedules were effective and without complications. Early diagnosis was the most important prognostic factor, but there was also recovery of function in about half of the patients unable to walk, and about one-third of patients with bladder dysfunction before treatment. Since length of the course of therapy is a factor with an important impact on the patient's quality of life, the short-course RT regimen adopted in the trial merits further investigation.
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Affiliation(s)
- E Maranzano
- Radiation Oncology Center, Policlinico Hospital of Perugia, Italy
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Tsagozis P, Bauer HCF. Spinal metastasis with neurologic deficits. Acta Orthop 2018; 89:229-233. [PMID: 29231771 PMCID: PMC5901523 DOI: 10.1080/17453674.2017.1412193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - A significant number of patients with spinal metastases are treated non-surgically, but may need surgical treatment at a later stage due to progression of symptoms. Therefore, we investigated the need for late surgical decompression in patients with spinal metastasis who were initially deemed as non-surgical candidates, as well as the outcome of late surgery. Patients and methods - 116 patients who were referred to the orthopedic oncology department between 2002 and 2011 due to spinal metastasis with neurologic symptoms were deemed to be non-surgical candidates. The primary reason was minor neurologic deficits in 40 patients (M) and short survival (S) in 76 patients. Results - 8 patients underwent a late operation due to progression of the neurologic symptoms, all of them belonged to group M. M-patients with a modified Bauer score of less than 2 had both an inferior survival as well as a higher risk for late surgery. Postoperative improvement in neurologic function was noted in 5/8 operated patients, whilst 2 patients had stationary symptoms and 1 deteriorated. Interpretation - The need for late surgery arises in a minority of patients with spinal metastasis primarily treated non-surgically, and only in patients with minor neurologic compromise rather than poor general condition. An established prognostic score (modified Bauer) can be used to guide decision-making. Late surgical decompression is effective in restoring the neurologic status.
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Affiliation(s)
- Panagiotis Tsagozis
- Section of Orthopedics, Department of Molecular Medicine and Surgery, Karolinska Institute,Department of Orthopedics, Karolinska University Hospital, Stockholm, Sweden,Correspondence:
| | - Henrik C F Bauer
- Section of Orthopedics, Department of Molecular Medicine and Surgery, Karolinska Institute,Department of Orthopedics, Karolinska University Hospital, Stockholm, Sweden
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He S, Wei H, Ma Y, Zhao J, Xu W, Xiao J. Outcomes of metastatic spinal cord compression secondary to primary hepatocellular carcinoma with multidisciplinary treatments. Oncotarget 2018; 8:43439-43449. [PMID: 28404935 PMCID: PMC5522159 DOI: 10.18632/oncotarget.15708] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 01/10/2017] [Indexed: 02/07/2023] Open
Abstract
Few studies have reported progression-free survival (PFS) and overall survival (OS) of Metastatic spinal cord compression (MSCC) patients with primary hepatocellular carcinoma (HCC) following surgery and adjuvant therapies. Enrolled in this study were 155 MSCC patients with primary HCC who received surgery and adjuvant therapies between 2000 and 2015. Kaplan-Meier methods and Cox’s proportional hazards regression mode were performed to investigate the clinical features and prognostic factors affecting PFS and OS. The median PFS and OS was 7.0 months and 9.7 months, respectively. 92.9% patients responded well to surgery according to the Visual Analogue Scale, Frankel Score and postoperative complication occurrences. 68 (43.9%) patients who received circumferential decompression achieved better PFS than the remaining 87 (56.1%) patients who received laminectomy. Favorable outcomes were achieved after surgery during the perioperative period. Circumferential decompression was associated with better PFS than laminectomy. The postoperative Frankel Score E, Eastern Cooperative Oncology Group performance score of 1 or 2, no visceral metastasis, administration of postoperative radiation and the use of Sorafenib were found to be significant predictors of better PFS and OS. Patients who previously underwent resection of primary HCC with/without liver transplantation tended to have a better OS.
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Affiliation(s)
- Shaohui He
- Department of Orthopedic Oncology, Spinal Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Haifeng Wei
- Department of Orthopedic Oncology, Spinal Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Yifei Ma
- Department of Orthopedic Oncology, Spinal Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Jian Zhao
- Department of Orthopedic Oncology, Spinal Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Wei Xu
- Department of Orthopedic Oncology, Spinal Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Jianru Xiao
- Department of Orthopedic Oncology, Spinal Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
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Aycan A, Celik S, Kuyumcu F, Akyol ME, Arslan M, Dogan E, Arslan H. Spinal Metastasis of Unknown Primary Accompanied by Neurologic Deficit or Vertebral Instability. World Neurosurg 2017; 109:e33-e42. [PMID: 28951274 DOI: 10.1016/j.wneu.2017.09.099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 09/14/2017] [Accepted: 09/15/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND OBJECTIVE Spinal bone metastases are common. They are mostly localized to the lumbar, thoracic, and cervical spine. The most common primaries to result in spinal metastases include lung, breast, and prostate carcinomas in adults as opposed to leukemia, Ewing sarcoma, rhabdomyosarcoma, and neuroblastoma in children. In patients diagnosed with cancer, bone metastases are found in 40% and spinal metastases in 10%. In this study, we reviewed 25 patients diagnosed with a spinal metastasis of unknown primary who presented with low back pain or acute-onset neurologic deficits and underwent operative treatment. METHODS The retrospective study included 25 patients with a spinal metastasis of unknown primary who presented to our clinic with acute-onset vertebral fracture or neurologic deficit. Statistical descriptions were obtained for each patient. Survival analysis was performed using the Kaplan-Meier method. RESULTS The 25 patients included 17 men (68%) and 8 women (32%), with a mean age of 55 years (range, 14-81 years). Eleven patients (44%) presented with varying degrees of motor deficits ranging from flaccid paralysis to paraplegia. Motor deficits were completely reversed in 4 patients postoperatively. The tumors were localized to the upper thoracic spine (T1-4) in 2 patients, in the midthoracic spine (T5-8) in 2 patients, in the lower thoracic spine (T9-12) in 8 patients, in the cervical 7 in 1 patient, and in the lumbar spine in 12 patients. In 10 patients, the tumor affected multiple spinal regions. Nonosseous tumors were not present in 10 patients. Ten patients had an extradural tumor. Costal involvement was detected in 2 patients. The tumors were pathologically identified as lung cancer (n = 3), lymphoma (n = 5), breast cancer (n = 3), gastric cancer (n = 2), liver cancer (n = 2), prostate cancer (n = 2), renal cell carcinoma (n = 2), malignant melanoma (n = 1), plasmacytoma (n = 1), bladder cancer (n = 1), paraganglioma (n = 1), Ewing sarcoma (n = 1), and yolk sac carcinoma (n = 1). Posterior instrumentation was performed in patients with instability. In addition, decompression was performed in patients with neurologic deficit. CONCLUSIONS Considering that 10% of patients with cancer are diagnosed by vertebral metastasis, presence of malignancy should be suspected and a detailed examination should be performed in patients presenting with vertebral fractures caused by no or minor trauma. Moreover, in patients presenting with neurologic deficit, soft tissue metastases leading to spinal cord compression should be kept in mind and further examinations should be promptly administered.
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Affiliation(s)
- Abdurrahman Aycan
- Department of Neurosurgery, Yuzuncu Yil University Medical School, Van, Turkey.
| | - Sebahattin Celik
- Department of General Surgery, Yuzuncu Yil University Medical School, Van, Turkey
| | - Fetullah Kuyumcu
- Department of Neurosurgery, Yuzuncu Yil University Medical School, Van, Turkey
| | - Mehmet Edip Akyol
- Department of Neurosurgery, Yuzuncu Yil University Medical School, Van, Turkey
| | - Mehmet Arslan
- Department of Neurosurgery, Yuzuncu Yil University Medical School, Van, Turkey
| | - Erkan Dogan
- Department of Medical Oncology, Yuzuncu Yil University Medical School, Van, Turkey
| | - Harun Arslan
- Department of Radiology, Yuzuncu Yil University Medical School, Van, Turkey
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Carrwik C, Murakami H, Willander J, Robinson Y. Potential harms of interventions for spinal metastatic disease. Hippokratia 2017. [DOI: 10.1002/14651858.cd012724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Christian Carrwik
- Uppsala University Hospital; Department of Surgical Sciences; Uppsala Sweden
| | - Hideki Murakami
- Kanazawa University; Department of Orthopaedic Surgery, Graduate School of Medical Science; 13-1 Takaramachi Kanazawa Japan 920-8641
| | | | - Yohan Robinson
- Uppsala University Hospital; Department of Surgical Sciences; Uppsala Sweden
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Husain ZA, Sahgal A, Chang EL, Maralani PJ, Kubicky CD, Redmond KJ, Fisher C, Laufer I, Lo SS. Modern approaches to the management of metastatic epidural spinal cord compression. CNS Oncol 2017; 6:231-241. [PMID: 28718323 PMCID: PMC6009217 DOI: 10.2217/cns-2016-0044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 02/28/2017] [Indexed: 12/25/2022] Open
Abstract
Metastatic epidural spinal cord compression (MESCC) is an oncologic emergency requiring prompt treatment to maximize neurologic function, ambulatory function and local control. Traditionally, options for MESCC included external beam radiation therapy with or without surgery. Surgery has usually been reserved for the patient with optimal performance status, single level MESCC or mechanical instability. Advances in external beam radiation therapy such as the development of stereotactic body radiation therapy have allowed for the delivery of high-dose radiation, allowing for both long-term pain and local control. Surgical advances, such as separation surgery, minimal access spine surgery and percutaneous instrumentation, have decreased surgical morbidity. This review summarizes the latest advances and evidence in MESCC to enable modern management.
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Affiliation(s)
- Zain A Husain
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT 06510, USA
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Science Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Eric L Chang
- Department of Radiation Oncology, Norris Cancer Center & Keck School of Medicine at University of Southern California, Los Angeles, CA 90033, USA
| | - Pejman Jabehdar Maralani
- Department of Medical imaging, Sunnybrook Health Science Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Charlotte D Kubicky
- Department of Radiation Medicine, Oregon Health Science Center, Portland, OR 97239, USA
| | - Kristin J Redmond
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Charles Fisher
- Department of Orthopaedic Surgery, University of British Columbia, Vancouver, BC V1Y 1T3, Canada
| | - Ilya Laufer
- Department of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, WA 98195, USA
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Tseng CL, Eppinga W, Charest-Morin R, Soliman H, Myrehaug S, Maralani PJ, Campbell M, Lee YK, Fisher C, Fehlings MG, Chang EL, Lo SS, Sahgal A. Spine Stereotactic Body Radiotherapy: Indications, Outcomes, and Points of Caution. Global Spine J 2017; 7:179-197. [PMID: 28507888 PMCID: PMC5415159 DOI: 10.1177/2192568217694016] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
STUDY DESIGN A broad narrative review. OBJECTIVES The objective of this article is to provide a technical review of spine stereotactic body radiotherapy (SBRT) planning and delivery, indications for treatment, outcomes, complications, and the challenges of response assessment. The surgical approach to spinal metastases is discussed with an overview of emerging minimally invasive techniques. METHODS A comprehensive review of the literature was conducted on the techniques, outcomes, and developments in SBRT and surgery for spinal metastases. RESULTS The optimal management of patients with spinal metastases is complex and requires multidisciplinary assessment from an oncologic team that is familiar with the shifting paradigm as a consequence of evolving techniques in surgery and stereotactic radiation, as well as new developments in systemic agents. The Spinal Instability Neoplastic Score and the epidural spinal cord compression (Bilsky) grading system are useful tools that facilitate communication among oncologic team members and can direct management by providing a baseline assessment of risks prior to therapy. The combined multimodality approach with "separation surgery" followed by postoperative spine SBRT achieves thecal sac decompression, improves tumor control, and avoids complications that may be associated with more extensive surgery. CONCLUSION Spine SBRT is a highly effective treatment that is capable of delivering ablative doses to the target while sparing the critical organs-at-risk, chiefly the critical neural tissues, within a short and manageable schedule. At the same time, surgery occupies an important role in select patients, particularly with the expanding availability and expertise in minimally invasive techniques. With rapid adoption of spine SBRT in centers outside of the academic setting, it is imperative for the practicing oncologist to understand the relevance and application of these evolving concepts.
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Affiliation(s)
- Chia-Lin Tseng
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada,Chia-Lin Tseng, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario, Canada M4 N 3M5.
| | - Wietse Eppinga
- University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Hany Soliman
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | | | - Mikki Campbell
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Young K. Lee
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Charles Fisher
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Eric L. Chang
- University of Southern California, Los Angeles, CA, USA
| | | | - Arjun Sahgal
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Ravindra VM, Brock A, Awad AW, Kalra R, Schmidt MH. The role of the mini-open thoracoscopic-assisted approach in the management of metastatic spine disease at the thoracolumbar junction. Neurosurg Focus 2017; 41:E16. [PMID: 27476840 DOI: 10.3171/2016.5.focus16162] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Objective Treatment advances have resulted in improved survival for many cancer types, and this, in turn, has led to an increased incidence of metastatic disease, specifically to the vertebral column. Surgical decompression and stabilization prior to radiation therapy have been shown to improve functional outcomes, but anterior access to the thoracolumbar junction may involve open thoracotomy, which can cause significant morbidity. The authors describe the treatment of 12 patients in whom a mini-open thoracoscopic-assisted approach (mini-open TAA) to the thoracolumbar junction was used to treat metastatic disease, with an analysis of outcomes. Methods The authors reviewed a retrospective cohort of patients treated for thoracolumbar junction metastatic disease with mini-open TAA between 2004 and 2016. Data collection included operative time, estimated blood loss, length of stay, follow-up duration, and pre- and postoperative visual analog scale scores and Frankel grades. Results Twelve patients underwent a mini-open TAA procedure for metastatic disease at the thoracolumbar junction. The mean age of patients was 59 years (range 53-77 years), mean estimated blood loss was 613 ml, and the mean duration of the mini-open TAA procedure was 234 minutes (3.8 hours). The median length of stay in the hospital was 7.5 days (range 5-21 days). All 12 patients had significant improvement in their postoperative pain scores in comparison with their preoperative pain scores (p < 0.001). No patients suffered from worsening neurological function after surgery, and of 7 patients who presented with neurological dysfunction, 6 (86%) had an improvement in their Frankel grade after surgery. No patients experienced delayed hardware failure requiring reoperation over a mean follow-up of 10 months (range 1-45 months). Conclusions The mini-open TAA to the thoracolumbar junction for metastatic disease is a durable procedure that has a reduced morbidity rate compared with traditional open thoracotomy for ventral decompression and fusion. It compares well with traditional and novel posterior approaches to the thoracolumbar junction. The authors found a significant improvement in preoperative pain and neurological symptoms that supports greater use of the mini-open TAA for the treatment of complex metastatic disease at the thoracolumbar junction.
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Affiliation(s)
- Vijay M Ravindra
- Department of Neurosurgery, Clinical Neurosciences Center and Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Andrea Brock
- Department of Neurosurgery, Clinical Neurosciences Center and Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Al-Wala Awad
- Department of Neurosurgery, Clinical Neurosciences Center and Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Ricky Kalra
- Department of Neurosurgery, Clinical Neurosciences Center and Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Meic H Schmidt
- Department of Neurosurgery, Clinical Neurosciences Center and Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
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Folkert MR, Timmerman RD. Stereotactic ablative body radiosurgery (SABR) or Stereotactic body radiation therapy (SBRT). Adv Drug Deliv Rev 2017; 109:3-14. [PMID: 27932046 DOI: 10.1016/j.addr.2016.11.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 11/28/2016] [Accepted: 11/30/2016] [Indexed: 12/25/2022]
Abstract
While conventional treatment relies on protracted courses of therapy using relatively small dose-per-fraction sizes of 1.8-2Gy, there is substantial evidence gathered over decades that this may not be the optimal approach for all targetable disease. Stereotactic ablative body radiosurgery (SABR) or stereotactic body radiation therapy (SBRT) is a technique which uses precise targeting to deliver high doses of radiation capable of ablating tumors directly. In this review, we will discuss the justification for and techniques used to deliver ablative doses to improve treatment outcomes, interactions with biological and immunologic therapy, and special procedures to spare normal tissue, which have facilitated the expanding role for these techniques in the management of a wide range of malignant histologies and disease states.
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Yáñez ML, Miller JJ, Batchelor TT. Diagnosis and treatment of epidural metastases. Cancer 2016; 123:1106-1114. [PMID: 28026861 DOI: 10.1002/cncr.30521] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 11/29/2016] [Accepted: 11/30/2016] [Indexed: 11/07/2022]
Abstract
Epidural metastases occur in 5% to 10% of cancer patients and represent a neurological emergency. Patients most commonly present with an acute onset of motor weakness, and restoration of neurological function is critically dependent on prompt diagnosis and treatment. This review discusses the clinical, epidemiological, and radiological features associated with epidural metastases and resulting spinal cord compression. Moreover, current treatment paradigms are reviewed. The timely initiation of radiation as well as surgery in select cases is critical for preserving neurological function and achieving local tumor control and pain control. Future studies investigating surgical and radiation treatment for metastatic epidural cord compression are urgently needed. Cancer 2017;123:1106-1114. © 2016 American Cancer Society.
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Affiliation(s)
- M Loreto Yáñez
- Department of Radiation Oncology, Arturo López Pérez Foundation, Santiago, Chile
| | - Julie J Miller
- Department of Neurology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Tracy T Batchelor
- Department of Neurology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts.,Department of Radiation Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts.,Division of Hematology/Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
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Zairi F, Karnoub MA, Vieillard MH, Bouras A, Marinho P, Allaoui M, Devos P, Assaker R. Evaluation of the relevance of surgery in a retrospective case series of patients who underwent the surgical treatment of a symptomatic spine metastasis from lung cancer. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:4052-4059. [PMID: 26821552 DOI: 10.1007/s00586-016-4397-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 01/11/2016] [Accepted: 01/15/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND The management of spine metastases is an increasing concern for spine surgeons. When considering surgery, it is crucial to ensure that its iatrogenic effects will not exceed its potential benefits, particularly in frail patients with short life expectancy. Among all prognostic factors, the primary site of cancer is the most important, lung cancer being the poorest. Although surgery has shown its effectiveness in the management of spine metastases, there is a lack of studies focusing on lung cancer alone. PURPOSE To assess the effectiveness and safety of surgery in the management of symptomatic spine metastases from lung cancer. METHODS We retrospectively reviewed all patients (n = 53) who underwent surgery for spine metastasis from lung cancer at the Lille University Hospital between January 2005 and December 2011. Patients for whom surgery was effective to restore or preserve ambulation, to relieve pain, and to ensure stability without severe complication were considered "surgical success". RESULTS No patient was lost to follow-up and vital status data were available for all patients. The median survival was 2.1 months and was not influenced by the surgical success (p = 0.1766). We reported seven major complications in seven patients, including three epidural haematoma, two massive pulmonary embolisms and two deaths from cardiopulmonary failure. The surgical success rate was 49 % and on univariate analysis, the factors that have influenced the postoperative outcome were the KPS (p < 0.001), the Frankel grade (p = 0.0217) and the delay between the cancer diagnosis and the occurrence of spine metastases (p = 0.0216). CONCLUSION A strict patient selection is required to limit the iatrogenic effect of surgery, which may alter the quality of life of these frail patients with limited life expectancy.
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Affiliation(s)
- Fahed Zairi
- Department of Neurosurgery, CHRU de Lille, 59000, Lille, France.
| | | | | | - Alkis Bouras
- Department of Neurosurgery, CHRU de Lille, 59000, Lille, France
| | - Paulo Marinho
- Department of Neurosurgery, CHRU de Lille, 59000, Lille, France
| | - Mohamed Allaoui
- Department of Neurosurgery, CHRU de Lille, 59000, Lille, France
| | - Patrick Devos
- Department of Biostatistics, Univ Lille, CHU Lille, EA2694, 59000, Lille, France
| | - Richard Assaker
- Department of Neurosurgery, CHRU de Lille, 59000, Lille, France
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Radiothérapie conformationnelle des métastases osseuses vertébrales. Cancer Radiother 2016; 20:493-9. [DOI: 10.1016/j.canrad.2016.07.081] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 07/24/2016] [Accepted: 07/29/2016] [Indexed: 12/25/2022]
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40
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Liu WM, Xing R, Bian C, Liang Y, Jiang L, Qian C, Dong J. Predictive value of pedicle involvement with MRI in spine metastases. Oncotarget 2016; 7:62697-62705. [PMID: 27486876 PMCID: PMC5308759 DOI: 10.18632/oncotarget.10884] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 06/17/2016] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES The study aimed to retrospectively evaluate the accuracy and value of magnetic resonance imaging (MRI) in predicting pedicle involvement for patients with spine metastases. METHODS Forty-five patients with a vertebral metastasis encroaching at least one pedicle were studied using MRI before surgery and regularly after surgery. Patients were categorized on the basis of their numbers of pedicle involvement (Group 1: one pedicle was involved, n = 23; Group 2: two pedicles were involved, n = 22). The diagnostic accuracy was calculated, and comparisons of intraoperative blood loss and recurrence rate between the two groups were performed. RESULTS The overall performance of MRI in predicting the pedicle involvement was as follows: accuracy, 94.4%; sensitivity, 95.5%; and specificity, 91.3%. Less intraoperative blood loss was observed for Group 1 compared with Group 2 (1,661 ± 672 ml and 2,173 ± 790 ml, respectively, P = 0.024). Tumor relapse occurred in 8.7% (2/23) of Group 1 and in 22.7% (5/22) of Group 2 with median recurrence free survival time 14 and 9 months, respectively. CONCLUSIONS MRI is a reliable approach to assess pedicle involvement. It has potential for use in the evaluation of the clinical characteristics of patients with spine metastases.
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Affiliation(s)
- Wang Mi Liu
- Department of Orthopedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Rong Xing
- Department of Orthopedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chong Bian
- Department of Orthopedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yun Liang
- Department of Orthopedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Libo Jiang
- Department of Orthopedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chen Qian
- Department of Orthopedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jian Dong
- Department of Orthopedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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Abi Lahoud G, Abi Jaoude S. [Role of surgery in the management of vertebral metastases. General revue]. Cancer Radiother 2016; 20:484-92. [PMID: 27614512 DOI: 10.1016/j.canrad.2016.07.086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 07/12/2016] [Accepted: 07/21/2016] [Indexed: 10/21/2022]
Abstract
The spine is the most common site of skeletal metastases. Treatment decisions for patients with spinal metastases can be challenging and greatly depend on survival prognosis. Surgery remains a valuable weapon in the therapeutic arsenal. A review of the literature describing the role of surgery, the various surgical approaches and the prognostic scores available for the management of spinal metastases was performed and summarized. Surgery for spinal metastases has 3 main objectives: management of pain, achievement of mechanical stability and preservation or restoration of neurological function. A variety of surgical approaches are available and depend on location of tumor, presence of instability, neurological status, oncologic prognosis, general performance status and subsequent treatment measures. The goal of any therapeutic course for a spinal metastasis is the best oncologic and functional result with the least aggressive treatment. Novelty surgical and adjunctive measures allow a multidisciplinary approach to the metastatic spine.
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Affiliation(s)
- G Abi Lahoud
- Unité de chirurgie de la colonne vertébrale et de la moelle épinière, service de neurochirurgie, centre hospitalier Sainte-Anne, 1, rue Cabanis, 75014 Paris, France.
| | - S Abi Jaoude
- Unité de chirurgie de la colonne vertébrale et de la moelle épinière, service de neurochirurgie, centre hospitalier Sainte-Anne, 1, rue Cabanis, 75014 Paris, France
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Boesen J, Johnsen A, Helweg-Larsen S, Sørensen PS. Diagnostic Value of Spinal Computer Tomography in Patients with Intraspinal Metastases Causing Complete Block on Myelography. Acta Radiol 2016. [DOI: 10.1177/028418519103200101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The value of post-myelographic spinal computer tomography (CT) was evaluated in cancer patients with spinal metastases causing complete myelographic block. In 22 out of 25 lumbar myelographies (88%) showing complete blockade, sufficient contrast medium had leaked proximally to allow determination of the cranial limit of the metastasis on the CT-scan. It is concluded that the post-myelographic spinal CT can replace a supplementary cervical myelography in the majority of patients with epidural metastasis, causing a complete myelographic block.
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Petteys RJ, Spitz SM, Rory Goodwin C, Abu-Bonsrah N, Bydon A, Witham TF, Wolinsky JP, Gokaslan ZL, Sciubba DM. Factors associated with improved survival following surgery for renal cell carcinoma spinal metastases. Neurosurg Focus 2016; 41:E13. [DOI: 10.3171/2016.5.focus16145] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Renal cell carcinoma (RCC) frequently metastasizes to the spine, causing pain or neurological dysfunction, and is often resistant to standard therapies. Spinal surgery is frequently required, but may result in high morbidity rates. The authors sought to identify prognostic factors and determine clinical outcomes in patients undergoing surgery for RCC spinal metastases.
METHODS
The authors searched the records of patients who had undergone spinal surgery for metastatic disease at a single institution during a 12-year period and retrieved data for 30 patients with metastatic RCC. The records were retrospectively reviewed for data on preoperative conditions, treatment, and survival. Statistical analyses (i.e., Kaplan-Meier survival analysis and log-rank test in univariate analysis) were performed with R version 2.15.2.
RESULTS
The 30 patients (23 men and 7 women with a mean age of 57.6 years [range 29–79 years]) had in total 40 spinal surgeries for metastatic RCC. The indications for surgery included pain (70%) and weakness (30%). Fourteen patients (47%) had a Spinal Instability Neoplastic Score (SINS) indicating indeterminate or impending instability, and 6 patients (20%) had a SINS denoting instability. The median length of postoperative survival estimated with Kaplan-Meier analysis was 11.4 months. Younger age (p = 0.001) and disease control at the primary site (p = 0.005), were both significantly associated with improved survival. In contrast, visceral (p = 0.002) and osseous (p = 0.009) metastases, nonambulatory status (p = 0.001), and major comorbidities (p = 0.015) were all significantly associated with decreased survival. Postoperative Frankel grades were the same or had improved in 78% of patients. Major complications occurred in 9 patients, and there were 3 deaths (10%) during the 30-day in-hospital period. Three en bloc resections were performed.
CONCLUSIONS
Resection and fixation may provide pain relief and neurological stabilization in patients with spinal metastases arising from RCC, but surgical morbidity rates remain high. Younger patients with solitary spinal metastases, good neurological function, and limited major comorbidities may have longer survival and may benefit from aggressive intervention.
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Affiliation(s)
- Rory J. Petteys
- 1Department of Neurosurgery, Georgetown University Hospital, Washington, DC
| | - Steven M. Spitz
- 1Department of Neurosurgery, Georgetown University Hospital, Washington, DC
| | - C. Rory Goodwin
- 2Department of Neurosurgery, The Johns Hopkins University, Baltimore, Maryland; and
| | - Nancy Abu-Bonsrah
- 2Department of Neurosurgery, The Johns Hopkins University, Baltimore, Maryland; and
| | - Ali Bydon
- 2Department of Neurosurgery, The Johns Hopkins University, Baltimore, Maryland; and
| | - Timothy F. Witham
- 2Department of Neurosurgery, The Johns Hopkins University, Baltimore, Maryland; and
| | - Jean-Paul Wolinsky
- 2Department of Neurosurgery, The Johns Hopkins University, Baltimore, Maryland; and
| | - Ziya L. Gokaslan
- 3Department of Neurosurgery, Brown University School of Medicine, Providence, Rhode Island
| | - Daniel M. Sciubba
- 2Department of Neurosurgery, The Johns Hopkins University, Baltimore, Maryland; and
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Cohen J, Alan N, Zhou J, Kojo Hamilton D. The 100 most cited articles in metastatic spine disease. Neurosurg Focus 2016; 41:E10. [DOI: 10.3171/2016.5.focus16158] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Despite the growing neurosurgical literature, a subset of pioneering studies have significantly impacted the field of metastatic spine disease. The purpose of this study was to identify and analyze the 100 most frequently cited articles in the field.
METHODS
A keyword search using the Thomson Reuters Web of Science was conducted to identify articles relevant to the field of metastatic spine disease. The results were filtered based on title and abstract analysis to identify the 100 most cited articles. Statistical analysis was used to characterize journal frequency, past and current citations, citation distribution over time, and author frequency.
RESULTS
The total number of citations for the final 100 articles ranged from 74 to 1169. Articles selected for the final list were published between 1940 and 2009. The years in which the greatest numbers of top-100 studies were published were 1990 and 2005, and the greatest number of citations occurred in 2012. The majority of articles were published in the journals Spine (15), Cancer (11), and the Journal of Neurosurgery (9). Forty-four individuals were listed as authors on 2 articles, 9 were listed as authors on 3 articles, and 2 were listed as authors on 4 articles in the top 100 list. The most cited article was the work by Batson (1169 citations) that was published in 1940 and described the role of the vertebral veins in the spread of metastases. The second most cited article was Patchell's 2005 study (594 citations) discussing decompressive resection of spinal cord metastases. The third most cited article was the 1978 study by Gilbert that evaluated treatment of epidural spinal cord compression due to metastatic tumor (560 citations).
CONCLUSIONS
The field of metastatic spine disease has witnessed numerous milestones and so it is increasingly important to recognize studies that have influenced the field. In this bibliographic study the authors identified and analyzed the most influential articles in the field of metastatic spine disease.
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Molina C, Rory Goodwin C, Abu-Bonsrah N, Elder BD, De la Garza Ramos R, Sciubba DM. Posterior approaches for symptomatic metastatic spinal cord compression. Neurosurg Focus 2016; 41:E11. [DOI: 10.3171/2016.5.focus16129] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Surgical interventions for spinal metastasis are commonly performed for mechanical stabilization, pain relief, preservation of neurological function, and local tumor reduction. Although multiple surgical approaches can be used for the treatment of metastatic spinal lesions, posterior approaches are commonly performed. In this study, the role of posterior surgical procedures in the treatment of spinal metastases was reviewed, including posterior laminectomy with and without instrumentation for stabilization, transpedicular corpectomy, and costotransversectomy. A review of the literature from 1980 to 2015 was performed using Medline, as was a review of the bibliographies of articles meeting preset inclusion criteria, to identify studies on the role of these posterior approaches among adults with spinal metastasis. Thirty-four articles were ultimately analyzed, including 1 randomized controlled trial, 6 prospective cohort studies, and 27 retrospective case reports and/or series. Some of the reviewed articles had Level II evidence indicating that laminectomy with stabilization can be recommended for improvement in neurological outcome and reduction of pain in selected patients. However, the use of laminectomy alone should be carefully considered. Additionally, transpedicular corpectomy and costotransversectomy can be recommended with the expectation of improving neurological outcomes and reducing pain in properly selected patients with spinal metastases. With improvements in the treatment paradigms for patients with spinal metastasis, as well as survival, surgical therapy will continue to play an important role in the management of spinal metastasis. While this review presents a window into determining the utility of posterior approaches, future prospective studies will provide essential data to better define the roles of the various options now available to surgeons in treating spinal metastases.
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Postoperative Stereotactic Body Radiation Therapy (SBRT) for Spine Metastases: A Critical Review to Guide Practice. Int J Radiat Oncol Biol Phys 2016; 95:1414-1428. [DOI: 10.1016/j.ijrobp.2016.03.027] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 01/08/2016] [Accepted: 03/21/2016] [Indexed: 11/18/2022]
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Nater A, Fehlings MG. Survival and clinical outcomes in patients with metastatic epidural spinal cord compression after spinal surgery: a prospective, multicenter, observational cohort study. CHINESE JOURNAL OF CANCER 2016; 35:27. [PMID: 26984792 PMCID: PMC4794915 DOI: 10.1186/s40880-016-0091-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 03/05/2016] [Indexed: 01/01/2023]
Abstract
Background High quality studies have been challenging to undertake in patients with metastatic epidural spinal cord compression. Nonetheless, in the article “Survival and Clinical Outcomes in Surgically Treated Patients With Metastatic Epidural Spinal Cord Compression: Results of the Prospective Multicenter AOSpine Study” recently published in the Journal of Clinical Oncology, our team provided convincing evidence that spinal surgery improves overall quality of life in patients with this potentially devastating complication of cancer. Considering that metastatic spinal lesions treated with surgery have the highest mean cost among all oncological musculo-skeletal issues, it is essential to provide high quality data to optimize the therapeutic approaches and cost-effective use of health care resources. Main body Although the AOSpine Study provided high quality prospective data, it was primarily limited by the lack of non-operative controls and the relatively small sample size. Given the dearth of medical equipoise and the fundamental difference between patients deemed to be adequate surgical candidates and those who are not amenable to operative intervention, conducting a randomized controlled trial in this patient population was not felt to be ethically or medically feasible. Consequently, the optimal option to overcome limitations of both the lack of controls and the relatively small sample size is through collection of large prospective datasets through rigorously developed and maintained registries. Conclusions With the alarming increase in the incidence of cancer in China and China’s parallel growing cancer control efforts, China would offer a fantastic platform to set up a national metastatic spinal lesion registry. Such registry would not only enhance metastatic epidural spinal cord compression translational research but also optimize patient care.
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Affiliation(s)
- Anick Nater
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | - Michael G Fehlings
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, ON, Canada. .,Division of Neurosurgery, Toronto Western Hospital, University Health Network, 399 Bathurst St., 4W-449, Toronto, ON, M5T 2S8, Canada.
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De la Garza-Ramos R, Benvenutti-Regato M, Caro-Osorio E. The 100 most-cited articles in spinal oncology. J Neurosurg Spine 2016; 24:810-23. [PMID: 26771372 DOI: 10.3171/2015.8.spine15674] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The authors' objective was to identify the 100 most-cited research articles in the field of spinal oncology. METHODS The Thomson Reuters Web of Science service was queried for the years 1864-2015 without language restrictions. Articles were sorted in descending order of the number of times they were cited by other studies, and all titles and abstracts were screened to identify the research areas of the top 100 articles. Levels of evidence were assigned on the basis of the North American Spine Society criteria. RESULTS The authors identified the 100 most-cited articles in spinal oncology, which collectively had been cited 20,771 times at the time of this writing. The oldest article on this top 100 list had been published in 1931, and the most recent in 2008; the most prolific decade was the 1990s, with 34 articles on this list having been published during that period. There were 4 studies with Level I evidence, 3 with Level II evidence, 9 with Level III evidence, 70 with Level IV evidence, and 2 with Level V evidence; levels of evidence were not assigned to 12 studies because they were not on therapeutic, prognostic, or diagnostic topics. Thirty-one unique journals contributed to the 100 articles, with the Journal of Neurosurgery contributing most of the articles (n = 25). The specialties covered included neurosurgery, orthopedic surgery, neurology, radiation oncology, and pathology. Sixty-seven articles reported clinical outcomes. The most common country of article origin was the United States (n = 62), followed by Canada (n = 8) and France (n = 7). The most common topics were spinal metastases (n = 35), intramedullary tumors (n = 18), chordoma (n = 17), intradural tumors (n = 7), vertebroplasty/kyphoplasty (n = 7), primary bone tumors (n = 6), and others (n = 10). One researcher had authored 6 studies on the top 100 list, and 7 authors had 3 studies each on this list. CONCLUSIONS This study identified the 100 most-cited research articles in the area of spinal oncology. The studies highlighted the multidisciplinary and multimodal nature of spinal tumor management. Recognition of historical articles may guide future spinal oncology research.
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Affiliation(s)
- Rafael De la Garza-Ramos
- Tecnológico de Monterrey, School of Medicine and Health Sciences; and.,Neurology and Neurosurgery Institute, Centro Médico Zambrano Hellion, TecSalud, Monterrey, Mexico
| | - Mario Benvenutti-Regato
- Tecnológico de Monterrey, School of Medicine and Health Sciences; and.,Neurology and Neurosurgery Institute, Centro Médico Zambrano Hellion, TecSalud, Monterrey, Mexico
| | - Enrique Caro-Osorio
- Tecnológico de Monterrey, School of Medicine and Health Sciences; and.,Neurology and Neurosurgery Institute, Centro Médico Zambrano Hellion, TecSalud, Monterrey, Mexico
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Zhang C, Wang G, Han X, Ren Z, Duo J. Comparison of the therapeutic effects of surgery combined with postoperative radiotherapy and standalone radiotherapy in treating spinal metastases of lung cancer. Clin Neurol Neurosurg 2015; 141:38-42. [PMID: 26731462 DOI: 10.1016/j.clineuro.2015.12.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 12/14/2015] [Accepted: 12/14/2015] [Indexed: 01/23/2023]
Abstract
OBJECT There are few studies comparing the therapeutic efficacy between surgery combined with postoperative radiotherapy and standalone radiotherapy in treating spinal metastases of lung cancer. The aim of this clinical study was to compare the clinical and functional efficacy, quality of life, and survival outcomes between surgery combined with postoperative radiotherapy and standalone radiotherapy in treating spinal metastases of lung cancer. METHODS A retrospective analysis of clinical data from June 2008 to December 2013 was performed with 46 patients suffering spinal metastases of lung cancer. Among the studied patients, 25 patients received standalone radiotherapy (radiotherapy group), and the other 21 patients received surgery combined with postoperative radiotherapy (surgery group). Follow-up and survival time were analyzed. Pain levels of the patients were assessed by visual analogue scale (VAS) from pre-treatment to one month and three months after starting treatment. 3 months after surgery, Neurologic deficit of the patients was evaluated using Frankel Grade, and functional impairment were classified by Karnofsky Score. The quality of life (QOL) was assessed by EORTC QLQ-C30 questionnaire. RESULTS The follow-up period of the patients ranged from 2 to 25 months with the average of 8.8 months. In radiotherapy group, the mean survival was 8.5 months with median survival time of 7.8 months. In surgery group, the mean survival was 10.6 months with median survival of 8.4 months. The difference in survival times between the two groups was not statistically significant (P=0.24>0.05). From pre-treatment to one month and three months after treatment initiation, the VAS in both groups showed statistical significant improvement (One month: P<0.01 Three months: P=0.001, p<<0.01). In the surgery group, 85.7% of all patients had functionally useful Frankel Grade D or E after surgery, compared with 71.4% pre-operatively. The percentage was 72.0% in the radiotherapy group post-treatment, compared with 68.0% pre-treatment. The relief of Frankel Grade in surgical group was superior to that of the radiotherapy group (p=0.025, p<0.01). KPS score (80-100) percentages in surgery group and in radiotherapy group were increased by 19% and 13.3%, respectively. The improvement of KPS was more in the surgery group (p=0.013, P<0.01). In radiotherapy group, the EORTC QLQ-C30 score was 86.13 ± 12.11 before treatment and 68.39 ± 14.96 after treatment. In surgery group, the EORTC QLQ-C30 score was 84.09 ± 9.48 before treatment and 54.64 ± 15.17 after treatment. The improvement of patient QOL was more in the surgery group (p=0.004, p<0.01). CONCLUSION Compared with standalone radiotherapy, surgery combined with postoperative radiotherapy did not significantly prolong the survival time. However, surgery can improve pain, function and QOL of patients with spinal metastases of lung cancer.
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Affiliation(s)
- Chao Zhang
- Department of Bone and Soft Tissue Tumor, Tianjin Medical University Cancer Institute and Hospital, Key Laboratory of Cancer Prevention and Therapy, China.
| | - Guowen Wang
- Department of Bone and Soft Tissue Tumor, Tianjin Medical University Cancer Institute and Hospital, Key Laboratory of Cancer Prevention and Therapy, China.
| | - Xiuxin Han
- Department of Bone and Soft Tissue Tumor, Tianjin Medical University Cancer Institute and Hospital, Key Laboratory of Cancer Prevention and Therapy, China
| | - Zhiwu Ren
- Department of Bone and Soft Tissue Tumor, Tianjin Medical University Cancer Institute and Hospital, Key Laboratory of Cancer Prevention and Therapy, China
| | - Jian Duo
- Department of Bone and Soft Tissue Tumor, Tianjin Medical University Cancer Institute and Hospital, Key Laboratory of Cancer Prevention and Therapy, China
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Quantitative Evaluation of Local Control and Wound Healing Following Surgery and Stereotactic Spine Radiosurgery for Spine Tumors. World Neurosurg 2015; 87:48-54. [PMID: 26548834 DOI: 10.1016/j.wneu.2015.10.075] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 10/21/2015] [Accepted: 10/22/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The present study evaluated the optimal measuring criteria to assess spinal tumor response to surgery followed by stereotactic spine radiosurgery (SRS) and reports the local control and wound complication rates following combined multimodality treatment. METHODS AND MATERIALS Prospectively collected patient information was retrospectively reviewed to identify patients treated with spine surgery followed by SRS. Tumor sizes and volumetric assessment were formally measured. Local control status was defined according to World Health Organization (WHO, bidimensional), RECIST (unidimensional), or volumetric size change. Statistical comparative assessments of tumor measurements were performed. RESULTS Twenty-two patients were eligible for evaluation after having undergone surgery followed by single-fraction SRS within a 2-month period. Seventeen had follow-up magnetic resonance imaging (MRI) with a mean patient follow-up of 12.59 months (range 3-36 months). None developed wound complication after radiation therapy (95% lower confidence bound 13%). Two patients had clinical recurrence while 15 of 17 achieved local control (88.3%). A test of marginal homogeneity for RECIST versus WHO was not statistically significant, P = 1.0 suggesting similar response classifications with both systems. Spearman correlations among 1) volumetric assessment, 2) bidimensional size, and 3) unidimensional size were significant for all groups (P < 0.05). CONCLUSION High local control rates can be achieved with surgery followed by SRS. Further, adjuvant SRS following spine tumor surgery delivers less radiation to the wound than conventional radiation and thus potentially reduces wound complications. Unidimensional, bidimensional, and volumetric tumor assessments demonstrate similar results. Hence the use of the simpler RECIST criteria is suitable and appropriate for evaluating the response to treatment after spine radiosurgery.
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