Ten Years After SINS: Role of Surgery and Radiotherapy in the Management of Patients With Vertebral Metastases

Enhancing the referral process for surgical management of spinal metastases: insights from a 12-year, bi-institutional study of 533 patients

Introduction

Delayed surgical management of spinal metastases (SMs) can have detrimental effects on patient survival and quality of life, leading to pain and potential neurological impairment. This study aimed to assess the impact of delayed referral for SMs on clinical outcomes by analyzing patients managed in emergency situations.

Methods

We retrospectively reviewed the data of all patients admitted on either emergency or elective basis who underwent surgery for the treatment of neoplastic spine lesions at our two institutions (tertiary referral neurosurgical units) between January 2008 and December 2019.

Results

We analyzed 210 elective (EGp) and 323 emergency patients (UGp); emergencies increased significantly over the 12-year period, with a Friday peak (39.3%) and frequent neurological impairment (61.6% vs. 20%). Among the UGp patients, 186 (7.5%) had a previously monitored primitive cancer, including 102 (31.6%) with known SMs. On admission, 71 of the 102 (69.9%) patients presented with neurological deficits. UGp patients were more likely to undergo a single decompression without fixation. Outcomes at the 3-month follow-up were significantly worse for UGp patients ([very] poor, 29.2 vs. 13.8%), and the median overall survival for UGp patients was statistically lower. Risk factors for patients with SM undergoing emergency management included short delay between onset of symptoms and first contact with a spine surgeon, and an initial motor deficit.

Conclusion

Many patients with previously identified metastases, including those with neurological deficits, are urgently referred. Optimization is needed in the oncology pathway, and all stakeholders must be made aware of the factors contributing to the improvement in the clinical and radiological identification of potential complications affecting patient survival and quality of life.

Imaging of Multiple Myeloma: Present and Future

Multiple myeloma (MM) is the second most common adult hematologic malignancy, and early intervention increases survival in asymptomatic high-risk patients. Imaging is crucial for the diagnosis and follow-up of MM, as the detection of bone and bone marrow lesions often dictates the decision to start treatment. Low-dose whole-body computed tomography (CT) is the modality of choice for the initial assessment, and dual-energy CT is a developing technique with the potential for detecting non-lytic marrow infiltration and evaluating the response to treatment. Magnetic resonance imaging (MRI) is more sensitive and specific than 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) for the detection of small focal lesions and diffuse marrow infiltration. However, FDG-PET/CT is recommended as the modality of choice for follow-up. Recently, diffusion-weighted MRI has become a new technique for the quantitative assessment of disease burden and therapy response. Although not widespread, we address current proposals for structured reporting to promote standardization and diminish variations. This review provides an up-to-date overview of MM imaging, indications, advantages, limitations, and recommended reporting of each technique. We also cover the main differential diagnosis and pitfalls and discuss the ongoing controversies and future directions, such as PET-MRI and artificial intelligence.

Treatment of an Impending Pathologic Sacral Fracture with a Novel Iliosacral Fusion Construct: A Case Report

CASE

A 49-year-old woman presented with left leg radiculopathy and posterior pelvic pain. Subsequent evaluation demonstrated metastatic multiple myeloma with an impending left S1 sacral fracture. Immediate posterior pelvic ring stabilization was recommended to prevent fracture and disruption of her oncologic recovery. This was performed percutaneously with computer-assisted navigation using a novel cannulated screw design.

CONCLUSION

The patient was treated with prophylactic percutaneous posterior pelvic ring fixation with a novel cannulated screw design that provided a durable construct for immediate weight-bearing. The fixation prevented a pathologic fracture and allowed immediate return to activity.

Multidisciplinary Approach to Spinal Metastases and Metastatic Spinal Cord Compression—A New Integrative Flowchart for Patient Management

Metastatic spine disease (MSD) and metastatic spinal cord compression (MSCC) are major causes of permanent neurological damage and long-term disability for cancer patients. The development of MSD is pathophysiologically framed by a cooperative interaction between general mechanisms of bone growth and specific mechanisms of spinal metastases (SM) expansion. SM most commonly affects the thoracic spine, even though multiple segments may be affected concomitantly. The great majority of SM are extradural, while intradural-extramedullary and intramedullary metastases are less frequently seen. The management of patients with SM is particularly complex and challenging, with multiple factors—such as the spinal stability status, primary tumor radio and chemosensitivity, cancer biological burden, patient performance status and comorbidities, and patient’s oncological prognosis—influencing the clinical decision-making process. Different frameworks were developed in order to systematize and support this process. A multidisciplinary, personalized approach, enriched by the expertise of each involved specialty, is crucial. We reviewed the most recent evidence and proposed an updated algorithmic approach to patients with MSD according to the clinical scenario of each patient. A flowchart-based approach offers an evidence-based management of MSD, providing a valuable clinical decision tool in a context of high uncertainty and quick-acting need.

Vertebral body collapse after radiotherapy for spinal metastases

Spinal metastases are common in patients with advanced stages of cancer and frequently cause vertebral body collapse (VBC). Although conventional radiotherapy (RT) is used for spinal metastases, the rates of occurrence of new VBC and progression of VBC at RT initiation have not been fully investigated. The present retrospective study assessed VBC and its associated risk factors after RT over time and evaluated new VBC and progression of VBC in patients who presented with VBC at RT initiation. The study evaluated 177 patients who received RT for vertebral metastases without paralysis between July 2012 and November 2016. Radiological responses of the irradiated vertebrae were assessed using computed tomography. Follow-up assessments were performed at RT initiation and 1, 2, 3, 4 and 6 months after RT. New VBC occurred in 12% of patients with no prior VBC within 1 month of RT. Multivariate analysis revealed that numeric rating scale (NRS) score (≥4) [relative risk (RR), 27.1; 95% confidence interval (CI), 1.86 to 394.9; P=0.016] was associated with the occurrence of new VBC at the 1 month follow-up time point. VBC progression occurred in 51% of the patients with collapse at RT initiation. Multivariate analysis revealed that bone quality (lytic metastases) (RR, 3.1; 95% CI, 1.28 to 7.70; P=0.013), NRS score (≥4) (RR, 3.0; 95% CI, 1.18 to 7.45; P=0.021) and tumor involvement of posterolateral elements of the spine (RR, 2.7; 95% CI, 1.03 to 7.29; P=0.04) were associated with the progression of VBC at the 1 month follow-up time point. The current study findings suggested that clinicians should pay attention to the factors that predict the occurrence of new VBC and VBC progression to ensure proper evaluation of conservative treatment effectiveness and facilitate the determination of patients who need close monitoring.