Diagnosis and treatment of vertebral column metastases

Unveiling Morphological Diversity: An Anatomical Investigation of the Foramen Transversarium in the Cervical Vertebrae

PURPOSE

This study aimed to investigate the morphological variations in the foramen transversarium of the cervical vertebrae and their clinical implications. Understanding these variations is crucial for accurate diagnosis, treatment planning, and surgical procedures involving the cervical spine.

MATERIALS AND METHODS

This descriptive cross-sectional study was conducted at the AIl India Institute of Medical Sciences, Bibinagar, India, and involved 150 dry cervical vertebrae specimens. Measurements of the anteroposterior and transverse dimensions, as well as anatomical variations such as accessory foramina and bilateral symmetry, were recorded using vernier calipers.

RESULTS

Out of 150 vertebrae, 149 had foramina on both sides, while one had a single foramen on the right. The anteroposterior diameter ranged from 1.0 to 10.0 mm on the right (mean: 5.13 ± 1.25 mm) and 2.0 to 8.5 mm on the left (mean: 5.08 ± 1.11 mm). The transverse diameter ranged from 2.0 to 9.0 mm on the right (mean: 5.54 ± 1.06 mm) and 2.0 to 8.0 mm on the left (mean: 5.42 ± 1.07 mm). Statistical analysis indicated symmetry in morphological dimensions. The morphological variations included unilateral and bilateral accessory foramina, incomplete accessory foramina, and asymmetrical foramina. Circular shapes were predominant (76% on the right, 75% on the left), with other shapes, such as oval and irregular shapes, being less common.

CONCLUSION

These findings enhance the understanding of cervical spine anatomy, aiding in the interpretation of radiographic images and the planning of surgical procedures. This research highlights the need for precise anatomical knowledge to improve patient outcomes in cervical spine-related interventions.

Dose-intensified stereotactic body radiotherapy for painful vertebral metastases: A randomized phase 3 trial

BACKGROUND

The purpose of this randomised study was to determine whether dose-intensified stereotactic body radiotherapy (SBRT) for painful vertebral metastases results in increased rates of pain improvement compared with conventional external beam radiotherapy (cEBRT) (control) 6 months after treatment.

METHODS

This randomized, controlled phase 3 trial was conducted between November 2016 and January 2023, when it was stopped early. Patients were eligible if they were aged 18 years or older; had one or two painful, stable, or potentially unstable vertebral metastases; and had a life expectancy of 1 year or longer according to the investigator's estimates. Patients received 48.5 grays (Gy) in 10 fractions (with epidural involvement) or 40 Gy in five fractions (without epidural involvement) in the SBRT group and 30 Gy in 10 fractions or 20 Gy in five fractions in the cEBRT group, respectively. The primary end point was an improvement in the pain score at the treated site by at least 2 points (on a visual analog scale from 0 to 10 points) at 6-month follow-up. Data were analyzed on an intention-to-treat and per-protocol basis.

RESULTS

Of 214 patients who were screened for eligibility, 63 were randomized 1:1 between SBRT (33 patients with 36 metastases) and cEBRT (30 patients with 31 metastases). The median age of all patients was 66 years, and 40 patients were men (63.5%). In the intention-to-treat analysis, the 6-month proportion of patients who had metastases with pain reduction by 2 or more points was significantly higher in the SBRT group versus the control group (69.4% vs. 41.9%, respectively; two-sided p = .02). Changes in opioid medication intake relative to baseline were nonsignificant between the groups. No differences were observed in vertebral compression fracture or adverse event rates between the groups.

CONCLUSIONS

Dose-intensified SBRT improved pain score more effectively than cEBRT at 6 months.

Electrochemotherapy in Spine Metastases: A Case Series Focused on Technical Aspects, Surgical Strategies and Results

Metastases are complications of primary tumors due to prolonged cancer survival and have become an important issue for oncological patients and the most frequent cause of death and disability. Bone metastases occur at a later stage of cancer disease, and the spine is the most frequent site. To date, the aim of the treatment of metastases remains to be the control of disease and provide a satisfactory quality of life. The decision making of treatment is influenced by several factors such as the status of the primary disease, the number of metastases, site involvement, and the performance status of the patients. For this reason, the treatment of metastases is challenging and undergoes constant development. Therefore, alternative techniques with respect to surgery, which is the first option but not always practicable, and radiochemotherapy are attractive. Lately, electrochemotherapy has emerged as an innovative method for treating various primary and metastatic solid tumors, showing promising outcomes in terms of inducing tumor tissue necrosis and alleviating symptoms. This technique uses electric pulses to increase the uptake of chemotherapy by tumor cells. Despite the initial enthusiasm and good results in the treatment of bone tumors, relatively few papers have described its use in spine metastases. Therefore, we conducted a systemic review of this intriguing topic while also reporting our experience in the use of electrochemotherapy for the treatment of spine metastases.

Evaluation of computed tomography artefacts of carbon-fiber and titanium implants in patients with spinal oligometastatic disease undergoing stereotactic ablative radiotherapy

This study evaluated artefacts on computed tomography (CT) images using Hounsfield units (HU) in patients with spinal oligometastatic disease who received carbon-fiber (CF; n = 11) or titanium (n = 11) spine implants and underwent stereotactic ablative radiotherapy (SABR). Pre- and postoperative HU were measured at the vertebral body, pedicle, and spinal cord at three different levels: the lower instrumented vertebra, the level of metastatic spinal cord compression, and an uninvolved level. Areas measured at each level were delicately matched pre- and postoperatively. Significant differences in HU were observed at the vertebral body, the pedicle, and the spinal cord at the lowest instrumented vertebra level for both CF and titanium (average increase 1.54-fold and 5.11-fold respectively). At the metastatic spinal cord compression level, a trend towards a higher HU-increase was observed in titanium compared with CF treated patients (average increase 2.51-fold and 1.43-fold respectively). The relatively high postoperative HU-increase after insertion of titanium implants indicated CT artefacts, while the relatively low HU-increase of CF implants was not associated with artefacts. Less CT artefacts could facilitate an easier contouring phase in radiotherapy planning. In addition, we propose a CT artefact grading system based on postoperative HU-increase. This system could serve as a valuable tool in future research to assess if less CT artefacts lead to time savings during radiotherapy treatment planning and, potentially, to better tumoricidal effects and less adverse effects if particle therapy would be administered.

Postoperative survival after lumbar instrumented surgery for metastatic spinal tumors: a nationwide population-based cohort analysis

BACKGROUND

It is difficult to predict the expected survival after lumbar instrumented surgery for metastases owing to the difference among different cancer origins and the relatively short survival after surgery.

AIMS

The aim of this study is to analyze the postoperative survival period of lumbar spinal metastasis patients who underwent lumbar instrumented surgery.

METHODS

Data were collected from the Korean National Health Insurance Review and Assessment Service database. Patients who underwent lumbar spinal surgery with instrumentation between January 2011 and December 2015 for metastatic lumbar diseases were reviewed. The mean postoperative survival period of patients with metastatic lumbar cancer according to each primary cancer type was evaluated.

RESULTS

A total of 628 patients were enrolled and categorized according to primary cancer type. The overall median survival rate was 1.11±1.30 years. The three most prevalent primary cancer groups were lung, hepatobiliary, and colorectal cancers, presenting relatively short postoperative survival rates (0.93±1.25, 0.74±0.75 and 0.74±0.88 years, respectively). The best postoperative survival period was observed in breast cancer (2.23±1.83 years), while urinary tract cancer showed the shortest postoperative survival period (0.59±0.69 years).

CONCLUSION

The postoperative survival period of patients with lumbar metastatic spinal tumors according to different primary cancers after instrumented fusion was ˃1 year overall, with differences according to different primary origins. This result may provide information regarding the expected postoperative survival after instrumented surgery for lumbar spinal metastases.

Risk Factors for Radiotherapy Failure in the Treatment of Spinal Metastases

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To build a predictive model for risk factors for failure of radiation therapy, hypothesizing a higher SINS would correlate with failure.

METHODS

Patients with spinal metastasis being treated with radiation at a tertiary care academic center between September 2014 and October 2018 were identified. The primary outcome measure was radiation therapy failure as defined by persistent pain, need for re-irradiation, or surgical intervention. Risk factors were primary tumor type, Karnofsky and ECOG scores, time to treatment, biologically effective dose (BED) calculations using α/β ratio = 10, and radiation modality. A logistic regression was used to construct a prediction model for radiation therapy failure.

RESULTS

One hundred and seventy patients were included. Median follow up was 91.5 days. Forty-three patients failed radiation therapy. Of those patients, 10 required repeat radiation and 7 underwent surgery. Thirty-six patients reported no pain relief, including some that required re-irradiation and surgery. Total SINS score for those who failed reduction therapy was <7 for 27 patients (62.8%), between 7-12 for 14 patients (32.6%), and >12 for 2 patients (4.6%). In the final prediction model, BED (OR .451 for BED > 43 compared to BED ≤ 43; P = .174), Karnofksy score (OR .736 for every 10 unit increase in Karnofksy score; P = .008), and gender (OR 2.147 for male compared to female; P = .053) are associated with risk of radiation failure (AUC .695). A statistically significant association between SINS score and radiation therapy failure was not found.

CONCLUSIONS

In the multivariable model, BED ≤ 43, lower Karnofksy score, and male gender are predictive for radiotherapy failure. SINS score was among the candidate risk factors included in multivariable model building procedure, but it was not selected in the final model.

LEVEL OF EVIDENCE

Prognostic level III.

Progressive resolution optimizer (PRO) predominates over photon optimizer (PO) in sparing of spinal cord for spine SABR VMAT plans

BACKGROUND

we assessed the performance of the optimization algorithms by comparing volumetric modulated arc therapy generated by a progressive resolution optimized (VMATPRO) and photon optimizer (VMATPO) in terms of plan quality, MU reduction, sparing of the spinal cord (or cauda equina), and plan complexity.

METHODS

Fifty-seven patients who received spine stereotactic ablative radiotherapy (SABR) with tumors located in the cervical, thoracic, and lumbar spine were retrospectively selected. For each patient, VMATPRO and VMATPO with two full arcs were generated with using the PRO and PO algorithms. For dosimetric evaluation, the dose-volumetric (DV) parameters of the planning target volume (PTV), organs at risk (OARs), the corresponding planning organs at risk (PRV), and 1.5-cm ring structure surrounding the PTV (Ring1.5 cm) were calculated for all VMAT plans. The total number of monitor units (MUs) and the modulation complexity score for the VMAT (MCSv) were compared. To investigate the correlations of OAR sparing to plan complexity, Pearson's and Spearman's correlation tests were conducted between the two algorithms (PO - PRO, denoted as Δ) in the DV parameters for normal tissues, total MUs, and MCSv.

RESULTS

For the PTVs, Target conformity and dose homogeneity in the PTVs of VMATPRO were better than those of VMATPO with statistical significance. For the spinal cords (or cauda equine) and the corresponding PRVs, all of the DV parameters for VMATPRO were markedly lower than those for VMATPO, with statistical significance (all p < 0.0001). Among them, the difference in the maximum dose to the spinal cord between VMATPRO and VMATPO was remarkable (9.04 Gy vs. 11.08 Gy with p < 0.0001). For Ring1.5 cm, no significant difference in V115% for VMATPRO and VMATPO was observed.

CONCLUSIONS

The use of VMATPRO resulted in improved coverage and uniformity of dose to the PTV, as well as OARs sparing, compared with that of VMATPO for cervical, thoracic, and lumbar spine SABR. Better dosimetric plan quality generated by the PRO algorithm was observed to result in higher total MUs and plan complexity. Therefore, careful evaluation of its deliverability should be performed with caution during the routine use of the PRO algorithm.

Posterior fossa melanocytic schwannoma extending to the cervicothoracic spinal cord: A clinical rarity

Background:

Melanocytic schwannomas (MSs) are rare, malignant peripheral nerve sheath tumors with only 200 cases reported to date. These pose imaging and pathological challenges for definitive diagnosis.

Case Description:

A 25-year-old lady presented at our center with a prolonged history of gait disturbance, left ear tinnitus, headaches, and drowsiness. MRI findings showed a midline cystic lesion in the posterior cranial fossa extending caudally to the D1 vertebral body, with marked central hypointensity, and peripheral hyperintensity on T1-weighted images. A suboccipital craniotomy and debulking of the lesion were performed, showing a hyperpigmented, infiltrative tumor adherent to the surrounding structures. This was confirmed as a melanocytic schwannoma on histopathological analysis.

Conclusion:

Posterior fossa MSs involving cervicomedullary region and extending distally to cervicothoracic spinal cord are rare and complex cases, particularly with regard to difficulty diagnosing preoperatively and surgical resection.

Holistic Approach to the Diagnosis and Treatment of Patients with Tumor Metastases to the Spine

The treatment of neoplastic spine metastases requires multi-faceted assessment and an interdisciplinary approach to patients. The metastases do not show specific symptoms but are often the first confirmation of the presence of a primary tumor in a patient. The diagnostic process includes imaging and invasive procedures, e.g., biopsy. It is essential to qualify the patient for an appropriate treatment using dedicated scales. Decompression of the spinal cord is a critical issue to save or restore neurological function in a patient with spine metastases. Surgical treatment ought to meet three criteria: release spinal cord and nerve roots, restore the spine’s anatomical relations, and ensure the internal stabilization of the spine. A good result from surgical treatment enables the continuation of radiotherapy, chemotherapy, hormone therapy, and targeted molecular therapy. Stereotactic radiosurgery and stereotactic body radiotherapy are more effective ways of treating spine metastases than conventional external beam radiotherapy. They allow higher doses of radiation, concentrated precisely at the tumor site. Our review summarizes the established and emerging concepts in the treatment of spine metastases. A holistic approach to the patient enables the selection of the appropriate therapy.

Precision of image-guided spinal stereotactic ablative radiotherapy and impact of positioning variables

Background and purpose

Spinal stereotactic ablative body radiotherapy (SABR) requires high precision. We evaluate the intrafraction motion during cone-beam computed tomography (CBCT) guided SABR with different immobilization techniques.

Material and methods

Fifty-seven consecutive patients were treated for 62 spinal lesions with SABR with positioning corrected in six degrees of freedom. A surface monitoring system was used for patient set up and to ensure patient immobilization in 65% of patients. Intrafractional motion was defined as the difference between the last CBCT before the start of treatment and the first CT afterwards.

Results

For all 194 fractions, the mean intrafractional motion was 0.1 cm (0-1.1 cm) in vertical direction, 0.1 cm (0-1.1 cm) in longitudinal direction and 0.1 cm (0-0.5 cm) in lateral direction. A mean pitch of 0.6° (0-4.3°), a roll of 0.5° (0-3.4°) and a rotational motion of 0.4° (0-3.9°) was observed. 95.5% of the translational errors and 95.4% of the rotational errors were within safety range. There was a significantly higher rotational motion for patients with arms along the body (p = 0.01) and without the use of the body mask (p = 0.05). For cervical locations a higher rotational motion was seen, although not significant (p = 0.1). The acquisition of an extra CBCT was correlated with a higher rotational (pitch) motion (p = 0 < 0.01).

Conclusion

Very high precision in CBCT guided and surface-guided spinal SABR was observed in this cohort. The lowest intrafraction motion was seen in patients treated with arms above their head and a body mask. The use of IGRT with surface monitoring is an added value for patient monitoring leading to treatment interruption if necessary.

Subregional radiomics analysis for the detection of the EGFR mutation on thoracic spinal metastases from lung cancer

The present study intended to use radiomic analysis of spinal metastasis subregions to detect epidermal growth factor receptor (EGFR) mutation. In total, 94 patients with thoracic spinal metastasis originated from primary lung adenocarcinoma (2017-2020) were studied. All patients underwent T1-weighted (T1W) and T2 fat-suppressed (T2FS) MRI scans. The spinal metastases (tumor region) were subdivided into phenotypically consistent subregions based on patient- and population-level clustering: Three subregions, S1, S2 and S3, and the total tumor region. Radiomics features were extracted from each subregion and from the whole tumor region as well. Least shrinkage and selection operator (LASSO) regression were used for feature selection and radiomics signature definition. Detection performance of S3 was better than all other regions using T1W (AUCs, S1 versus S2 versus S3 versus whole tumor, 0.720 versus 0.764 versus 0.786 versus 0.758) and T2FS (AUCs, S1 versus S2 versus S3 versus whole tumor, 0.791 versus 0.708 versus 0.838 versus 0.797) MRI. The multi-regional radiomics signature derived from the joint of inner subregion S3 from T1W and T2FS MRI achieved the best detection capabilities with AUCs of 0.879 (ACC = 0.774, SEN = 0.838, SPE = 0.840) and 0.777 (ACC = 0.688, SEN = 0.947, SPE = 0.615) in the training and test sets, respectively. Our study revealed that MRI-based radiomic analysis of spinal metastasis subregions has the potential to detect the EGFR mutation in patients with primary lung adenocarcinoma.

Progress of Phototherapy Applications in the Treatment of Bone Cancer

Bone cancer including primary bone cancer and metastatic bone cancer, remains a challenge claiming millions of lives and affecting the life quality of survivors. Conventional treatments of bone cancer include wide surgical resection, radiotherapy, and chemotherapy. However, some bone cancer cells may remain or recur in the local area after resection, some are highly resistant to chemotherapy, and some are insensitive to radiotherapy. Phototherapy (PT) including photodynamic therapy (PDT) and photothermal therapy (PTT), is a clinically approved, minimally invasive, and highly selective treatment, and has been widely reported for cancer therapy. Under the irradiation of light of a specific wavelength, the photosensitizer (PS) in PDT can cause the increase of intracellular ROS and the photothermal agent (PTA) in PTT can induce photothermal conversion, leading to the tumoricidal effects. In this review, the progress of PT applications in the treatment of bone cancer has been outlined and summarized, and some envisioned challenges and future perspectives have been mentioned. This review provides the current state of the art regarding PDT and PTT in bone cancer and inspiration for future studies on PT.

Performance of Computed Tomography-Guided Spine Biopsy for the Diagnosis of Malignancy and Infection

BACKGROUND

Computed tomography (CT)-guided percutaneous biopsies are used to guide treatment in vertebral osteomyelitis and spinal malignancy, but the efficacy of this study remains unclear.

OBJECTIVE

To investigate the performance of CT-guided spinal biopsy, and factors that may influence its success.

METHODS

Retrospective study of all consecutive patients who underwent a CT-guided spine biopsy at a UK teaching hospital between April 2012 and February 2019. Biopsies were performed by 3 consultant neuroradiologists for a lesion suggestive of either malignancy or infection. Data collection included patient factors, biopsy factors, further investigations required, and diagnosis. Data were analyzed using contingency tables, analysis of variance, unpaired t-test, chi-squared test, and Fisher's exact test.

RESULTS

A total of 124 percutaneous biopsies were performed on 109 patients with a mean follow-up of 34.5 mo (range 4-86 mo) and a mean age of 66 yr (range 27-93). Approximately 32.3% (n = 40) of the biopsies investigated possible infection, and 67.7% investigated malignancy. The sensitivity for infected cases was 37.0%, and for malignancy 72.7%. The diagnostic accuracy was 57.5% and 78.6%, respectively. Complication rate was 1.6%. In our study, neither needle gauge, anatomic level of the biopsy, or bone quality significantly affected the rate of positive biopsy.

CONCLUSION

Both in our study and in the wider literature, CT-guided biopsy has a vastly superior sensitivity for malignancy compared with suspected infection. These procedures may be painful, poorly tolerated, and are not entirely risk free. As such we advocate judicious use of this modality particularly in cases of suspected infection.

[Treatment strategies for pathological fractures of the spine]

BACKGROUND

Pathological fractures and instabilities of the spine are most often caused by primary tumors that hematogenously metastasize into the spine. In this context breast, prostate, kidney cell and bronchial carcinomas are the most relevant causative diseases. Furthermore, multiple myeloma is another frequent entity. Primary tumors of the spine are correspondingly rare and only make up a small proportion of all malignant processes in the spine.

DECISION MAKING

The main symptom of pain is prognostically unfavorable in this context and is often associated with progressive instability or pathological fractures. To objectify the treatment approach the neurological status, an oncological assessment, the biomechanical stability and (systemic) general condition (NOMS criteria) of the patient have to be considered. Another major factor is the radiation sensitivity of the tumor. The spinal instability neoplastic (SIN) score is recommended to assess stability. Regardless of whether conservative or surgical treatment is carried out, interdisciplinary cooperation between the specialist departments must be guaranteed in order to achieve adequate treatment for the patient.

TREATMENT

If a curative approach is followed an individualized and interdisciplinary surgical strategy must be performed to achieve an R0 resection, usually as a spondylectomy. In the case of palliative treatment, the goal of surgical treatment must be pain reduction, stability and avoidance or restoration of neurological deficits. This requires stabilization in a percutaneous or open technique, possibly in combination with decompression and local tumor debulking.

Phase 1 study of spinal cord constraint relaxation with single session spine stereotactic radiosurgery in the primary management of patients with inoperable, previously irradiated metastatic epidural spinal cord compression

Background

Patients with previously irradiated metastatic epidural spinal cord compression (MESCC) who are not surgical candidates are at high risk of neurologic deterioration due to disease in the setting of limited treatment options. We seek to establish the feasibility of using salvage spine stereotactic radiosurgery (SSRS) allowing for spinal cord dose constraint relaxation as the primary management of MESCC in inoperable patients monitoring for radiation related toxicity and radiographic local control (LC).

Methods

Inoperable patients with previously irradiated MESCC were enrolled on this prospective Phase 1 single institution protocol. Single fraction SSRS was delivered to a prescription dose of 18 Gy. Spinal cord constraint relaxation was performed incrementally from an initial allowable Dmax cohort of 8 Gy to 14 Gy in the final planned cohort. Patients were monitored every 3 months with follow-up visits and MRI scans.

Results

The trial was closed early due to slow accrual. From 2011 to 2014, 11 patients were enrolled of which 9 patients received SSRS. Five patients were in the 8 Gy cord Dmax cohort and 4 in the 10 Gy cord Dmax cohort.

The median overall survival (OS) was 11.9 months (95% CI 7.1, 22 months). Of the 9 patients treated with SSRS, 1 died prior to post-SSRS evaluation. Of the remaining 8 patients, 5 experienced a local failure. Three of the five were treated with surgery while two received systemic therapy. Two of the five failures ultimately resulted in loss of neurologic function. The median LC was 9.1 months (95%CI 4.8, 20.1 months). With a median clinical follow-up of 6.8 months, there were no cases of RM.

Conclusions

Despite the limited life expectancy in this high-risk cohort of patients, strategies to optimize LC are necessary to prevent neurologic deterioration. Larger prospective trials exploring optimal dose/fractionation and cord constraints are required.

Characteristics of Patients and Treatment Recommendations from a Multidisciplinary Spinal Tumor Program

Objective: We describe characteristics of patient and treatment recommendations from a spinal tumor board at one institution, including representation from palliative care.

Background: The impact of prospective multidisciplinary input for patients with spinal tumors is poorly understood despite their increasing complexity.

Methods: We retrospectively reviewed 622 cases sequentially discussed at a weekly spinal tumor board, and abstracted patient and treatment information from the medical record and meeting minutes.

Results: From April 2017 to February 2019, 622 cases representing 438 unique patients were discussed. The median age was 62 years (range 21–92). Most patients had spinal tumors originating from metastases (91.78%), including breast (14.3%), nonsmall cell lung cancer (13.4%), prostate (10.9%), and renal cell cancer (8.8%), and the remainder had primary central nervous system (4.3%) or benign tumors (3.9%). Sixty-five percent of patients were alive at last follow-up. Conventional external beam radiotherapy was the most common treatment recommendation (33.8%) followed by surgery (26.2%), stereotactic body radiation therapy (17.8%), imaging follow-up (16.6%), and vertebroplasty (15.9%). Palliative care was the primary treatment recommended for 4.5%, and no therapy recommended for 4.0%. Treatment recommendation involved two modalities for 29% of cases, and three in 1.3% of cases. In four cases, biopsy to confirm pathology changed management due to unexpected findings of osteomyelitis, hematopoiesis, or new diagnosis of plasmacytoma.

Conclusions: Multidisciplinary input is integral to the optimal care of spinal tumor patients. The high risk of death highlights the need to prioritize modalities that optimize quality of life in the context of a patient's individual prognosis.

Incidence and Risk Factors for Implant Failure in Spinal Metastasis Surgery

STUDY DESIGN

Retrospective study.

PURPOSE

To investigate the incidence of symptomatic and asymptomatic implant failure in spinal metastasis surgery and identify potential risk factors.

OVERVIEW OF LITERATURE

Surgical stabilization with instrumentation is an established method for the treatment of spinal metastasis. However, very few studies have investigated the incidence and risk factors for implant failure after spinal instrumentation surgery for the treatment of spinal metastasis.

METHODS

This study recruited 88 patients who received surgical stabilization with instrumentation for the treatment of spinal metastasis. Their medical records and postoperative X-rays were reviewed for evidence of implant failure. Statistical analysis with logistic regression was performed to assess nine potential risk factors for the development of implant failure, including patient's age at operation, gender, survival, primary tumor, spinal level involved, construct length, decompression levels, fusion material utilization, and radiotherapy application either before or after surgery, to identify potential contributing risk factors.

RESULTS

Implant failure was identified in nine out of 88 cases (10.2%) with two cases requiring implant removal: one case included a progressive kyphosis that resulted in nonhealing sore and the other involved a deep-seated wound infection that spread to the implants. Another case required wound debridement due to superficial wound infection. The remaining six cases were asymptomatic, despite postoperative X-rays demonstrating evidence of implant failure. No patient required implant revision. Logistic regression analysis demonstrated that patients who received radiotherapy either before or after surgery were less likely to develop implant failure.

CONCLUSIONS

The development of radiological implant failure following surgical treatment of spinal metastasis is common. However, symptomatic implant failure leading to revision surgery is uncommon. Our findings suggest that radiotherapy, either before or after spinal surgery, is not associated with the development of implant failure.

Outcome and toxicity of hypofractionated image-guided SABR for spinal oligometastases

•

Hypofractionated stereotactic ablative radiotherapy (SABR) in patients with spinal oligometastases.

•

High rates of efficacy and minimal toxicity.

•

Oligometastatic patients with metachronous spinal metastases seem to benefit the most.

Background

To investigate progression free survival (PFS), local control (LC) and overall survival (OS) outcomes for patients treated with spine hypofractionated stereotactic ablative radiotherapy (SABR) and to evaluate possible predictors of rapid progression in view of a correct patient selection for this potentially curative SABR.

Materials and methods

A cohort of 59 patients with spinal metastases were treated with SABR. Patient selection criteria were the following: histologically proven diagnosis of a solid tumor, a World Health Organization (WHO) score ≤ 2, life expectancy > 6 months, Spinal Instability Neoplastic Score (SINS) ≤ 12 points and presenting with radically treated oligometastatic disease (≤5 lesions) or stable polymetastatic disease with an oligoprogressive lesion.

Results

From March 2015 to June 2019, 59 patients were treated with Linac-based SABR to 64 spinal metastases with a median follow-up of 55 months. SABR was standard delivered every other day in 3 to 10 fractions with median prescription dose of 27 Gy (range 21–49 Gy).

The 1-,2- and 5-year PFS was 98%, 85% and 75% for all patients. OS at 5 years for all patients was 92%. Metachronous lesions (p < 0.01; HR = 7.1) and oligometastatic (vs. oligoprogressive) lesions (p = 0.02; HR = 0.3) were associated with higher PFS in uni- and multivariate Cox regression analysis. No significant predictors in multivariate analysis were demonstrated for rapid progressors.

Vertebral compression fractures developed de novo in 6.3% (4/64) of cases. The median time to fracture was 11 months (range 7–15) after treatment. No other adverse events ≥ 3 grade were observed.

Conclusions

Tumor control and toxicity after high-dose hypofractionated SABR was evaluated in patients with spinal oligometastases. High rates of efficacy and minimal toxicity were demonstrated. Oligometastatic patients with metachronous spinal metastases seem to benefit the most from SABR.

Stereotactic Radiation for Treating Primary and Metastatic Neoplasms of the Spinal Cord

Stereotactic radiation treatment can be used to treat spinal cord neoplasms in patients with either unresectable lesions or residual disease after surgical resection. While treatment guidelines have been suggested for epidural lesions, the utility of stereotactic radiation for intradural and intramedullary malignancies is still debated. Prior reports have suggested that stereotactic radiation approaches can be used for effective tumor control and symptom management. Treatment-related toxicity has been documented in rare subsets of patients, though the incidences of injury are not directly correlated with higher radiation doses. Further studies are needed to assess the factors that influence the risk of radiation-induced myelopathy when treating spinal cord neoplasms with stereotactic radiation, which can include, but may not be limited to, maximum dose, dose-fractionation, irradiated volume, tumor location, histology and treatment history. This review will discuss evidence for current treatment approaches.

Research on the predicting power of the revised Tokuhashi system: how much time can surgery give to patients with short life expectancy?

Object

The primary treatment option for symptomatic metastatic spinal tumors is surgery. Prognostic systems are designed to assist in the establishment of the indication and the choice of surgical methodology. The best-known prognostic system is the revised Tokuhashi system, which has a predictive ability of about 60%. In our study, we are attempting to find the reason for its poor predictive ability, despite its proper separation ability.

Methods

We have designed a one-center-based retrospective clinical trial, by which we would like to test the feasibility and the inaccuracy of the revised Tokuhashi system. In our database, there are 329 patients who underwent surgery. Statistical analysis was performed.

Results

A significant increase in survival time was observed in the ‘conservative’ category. Earlier studies reported OS 0.15 at the 180-day control time, in contrast with our 0.38 OS value. The literature suggested supportive care for this category, but in our population, every patient underwent surgery. Our population passes the 0.15 OS value on day 475. We propose an adjustment of the Tokuhashi category scores. We observed significant success in resolving pain. Motor functions were improved or stabilized compared to changes in vegetative dysfunction.

Conclusion

According to our results, the Tokuhashi scoring system makes very conservative predictions and prefers non-surgical palliative or supportive care. Surgical treatment increases the life expectancy of patients in poor condition. We propose modifying the therapeutic options of the revised Tokuhashi system, taking into consideration modern spine surgery techniques.

Adjacent level fracture incidence in single fraction high dose spinal radiosurgery

Background

Vertebral body compression fracture (VCF) is a complication following spinal stereotactic radiosurgery (SRS). However, the incidence of VCF in vertebrae adjacent to the level of SRS is unknown. This study aimed to determine the incidence of adjacent level VCF (adjVCF) following spinal SRS.

Methods

A retrospective review of 239 lesions treated with single-fraction SRS from 2011-2014 was performed. Clinical and pathologic factors were collected including evaluation of VCFs in adjacent levels to SRS site. In patients with adjVCFs, dose-volume histograms for adjacent-level endplates were calculated. Cox regression analysis was performed to determine any association among clinical factors and adjVCF occurrence.

Results

Median follow-up was 14.7 months. Twenty-six adjVCFs occurred (10.8%). Of the adjVCFs, 19 had metastases following SRS, and seven did not (2.9% of total treatments). Median time to fracture post-SRS was 13.5 months. In adjVCFs, median of the mean dose to adjacent level fractured endplate was 23.3 Gy, and median of the mean dose of sixteen non-fractured endplates immediately adjacent to the SRS site was 19.1 Gy. Age, gender, and histology were not associated with adjVCF.

Conclusions

AdjVCF after spinal SRS occurs at a rate of 2.9%, when excluding metastatic sites of disease. Adjacent level endplates should be investigated as an organ at risk during SRS planning.

Electrochemotherapy of Spinal Metastases Using Transpedicular Approach-A Numerical Feasibility Study

Vertebral column is the most frequent site for bone metastases. It has been demonstrated in previous studies that bone metastases can be efficiently treated by electrochemotherapy. We developed a novel approach to treat spinal metastases, that is, transpedicular approach that combines electrochemotherapy with already established technologies for insertion of fixation screws in spinal surgery. In the transpedicular approach, needle electrodes are inserted into the vertebral body through pedicles and placed around the tumor. The main goal of our study was to numerically investigate the feasibility of the proposed treatment approach. Three clinical cases were used in this study—1 with a tumor completely contained within the vertebral body and 2 with tumors spread also to the pedicles and spinal canal. Anatomically accurate numerical models were built for all 3 cases, and numerical computations of electric field distribution in tumor and surrounding tissue were performed to determine the treatment outcome. Complete coverage of tumor volume with sufficiently high electric field is a prerequisite for successful electrochemotherapy. Close to 100% tumor coverage was obtained in all 3 cases studied. Two cases exhibited tumor coverage of >99%, while the coverage in the third case was 98.88%. Tumor tissue that remained untreated was positioned on the margin of the tumor volume. We also evaluated hypothetical damage to spinal cord and nerves. Only 1 case, which featured a tumor grown into the spinal canal, exhibited potential risk of neural damage. Our study shows that the proposed transpedicular approach to treat spinal metastases is feasible and safe if the majority of tumor volume is contained within the vertebral body. In cases where the spinal cord and nerves are contained within the margin of the tumor volume, a successful and safe treatment is still possible, but special attention needs to be given to evaluation of potential neural damage.

Re-irradiation for painful bone metastases using stereotactic body radiotherapy

PURPOSE

Stereotactic body radiotherapy (SBRT) is expected to achieve safe and effective re-irradiation for painful bone metastases. This study aimed to clarify the efficacy of re-irradiation using SBRT for painful bone metastases.

METHODS

Prospective database at our institution for the period between September 2013 and December 2017 were retrospectively reviewed for patients with: (1) painful bone metastases; (2) history of radiotherapy to the metastasis; and (3) SBRT performed as re-irradiation. Pain response, pain failure-free duration, analgesics medications, and adverse events were evaluated. Pain was evaluated using the Numerical Rating Pain Score, and pain response was evaluated based on International Consensus Pain Response Endpoints. Best response during follow-up was noted. Patients with complete or partial response were defined as showing pain response, and patients with pain progression were defined as showing pain failure. Adverse events were evaluated based on the RTOG/EORTC Late Radiation Morbidity Scoring Schema.

RESULTS

Sixty-six patients selected from our database showed: median age, 65 years (range, 33-82 years); ECOG performance status, 0-1/2/3/4, 51/10/3/2; lesion histopathology, rectal/lung/renal/thyroid/other cancer, 13/11/9/5/28; median previous irradiated dose, 30 Gy (range, 8-70.4 Gy); median interval from latest irradiation, 21 months (range, 4-192 months); prescribed dose for SBRT, 24 Gy in 2 fractions/30 Gy in 5 fractions/35 Gy in 5 fractions, 51/13/2. Median follow-up after SBRT was 10 months (range, 1-37 months). Fifty-seven patients achieved pain response (86%). The 1-year pain failure-free rate was 55%. Median pain failure-free duration was 13 months (range, 1-24 months). Grade 4 adverse events were observed in six patients (vertebral compression fracture, n = 5; radiation myelopathy, n = 1). No other toxicities of Grade 3 or greater were encountered.

CONCLUSIONS

Re-irradiation SBRT has potential to achieve good response and long-term pain control for painful bone metastases. Prospective analysis is necessary to confirm the safety and efficacy of SBRT as re-irradiation.

Management - spinal metastases

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.

Utility of Computed Tomography-guided Biopsy in Evaluation of Metastatic Spinal Lesions

INTRODUCTION

Computed tomography (CT)-guided biopsy of spine is currently a valuable diagnostic tool and effective technique for diagnosing and planning a proper therapeutic strategy for certain spinal lesions. The reported diagnostic accuracy of core biopsy ranges from 77% to 97%.

MATERIALS AND METHODS

We included all patients with spinal lesions suspicious of metastasis on magnetic resonance imaging, who presented between May 2012 and April 2014 and underwent CT-guided biopsy in our study. A total of thirty patients with spinal lesions were evaluated.

RESULTS

Majority presented in the seventh decade of their life (average age = 53.93; age range = 10-72 years). Male:female ratio was 1.5:1. Pain was the most common presenting symptom (100%). Lumbar spine was the most common site of lesion followed by dorsal spine. Biopsy is the gold standard in histopathological evaluation of spinal lesions. Metastatic lesion was diagnosed in 12 (40%) cases, plasmacytoma in 12 (40%) cases, non-Hodgkin's lymphoma in 2 (6.66%) cases, small round cell tumor in 1 (3.33%) case, nonspecific chronic inflammation in two patients, and necrosis with no viable cells in one patient. The most common malignancy to metastasize to spine was adenocarcinoma. The most common primary tumor of spine was plasmacytoma - multiple myeloma.

CONCLUSION

CCT-guided biopsy is a safe procedure, and no procedure-related complication was seen in any patient.

Analysis of factors delaying the surgical treatment of patients with neurological deficits in the course of spinal metastatic disease

Background

Thoracic spine cancer metastases is frequently the cause of neurological deficits. Despite the availability of diagnostics, delays in treatment are still quite common. The aim of this work is to analyze the reasons for delayed diagnostics and treatment, in patients with neurological deficits in the course of metastatic spine disease.

Methods

In our study patients medical data was analyzed from 2013 to 2015. The analysis covered the following aspects: symptoms of metastases, time of neurological deficits occurrence, where and when initial diagnostics were performed, time from diagnosis to proper surgical treatment in an oncological centre. In total, 411 patients were consulted and 287 were operated on. Of 112 patients with neurological deficits, 64 underwent surgeries. Women represented the majority of the patients. The most common primary neoplasms were breast cancer and myeloma.

Results

In 75% of the patients neurological symptoms occurred prior to admission to a hospital. The average time between the onset of neurological symptoms and medical consultation was 4 days. The patients were diagnosed mainly at neurologic, orthopedic and emergency departments. The mean time between undergoing radiological examinations and receiving the examinations results was 2.4 days for CT and 2.8 days for MRI. The average time between a patients’ admission from the department where they were initially diagnosed, to the orthopedic oncology ward was 4.5 days.

Conclusions

The most common cause of the delayed treatment of patients with neurological deficits, in the course of metastatic spine disease, is a combination of the lack of knowledge among patients and healthcare personnel regarding the necessity of early diagnosis.

Instrumented Spinal Stabilization without Fusion for Spinal Metastatic Disease

OBJECTIVES

Spinal stabilization surgery is an integral part of the treatment of spinal metastatic disease. Bony fusion is the hallmark of spinal stabilization in non-oncology patients. Spinal oncology patients are unlikely to achieve bony fusion because of their overall prognosis and concurrent therapies. Stabilization surgery without fusion may be a reasonable approach for these patients. Literature evaluating the effectiveness of this approach is limited. The object of this study was to investigate the rate of instrumentation failure in patients undergoing posterior spinal instrumented stabilization without fusion for spinal metastatic disease.

METHODS

Data from consecutive cases of spinal surgery at our institution during an 81-month period were reviewed. Demographics, clinical notes, and computed tomography findings were recorded and used to evaluate instrumentation failures. Patients who underwent separation surgery that included laminectomy and posterior spinal instrumentation without fusion for spinal metastatic disease and had follow-up computed tomography scans >3 months postoperatively were selected for the study.

RESULTS

Twenty-seven patients were included in the study. Mean age was 64.85 ± 6.53 years. Nine patients were women. A mean of 1.61 ± 0.96 laminectomy levels was performed. A mean of 8.26 ± 1.48 screws was inserted. The mean postoperative discharge date was 5.07 ± 1.47 days. Mean follow-up duration was 12.17 ± 11.73 months. None of the patients had a change in instrumentation position, pedicle screw pullout, change in spinal alignment, or progressive deformity. No patient required reoperation or instrumentation revision or replacement.

CONCLUSIONS

Our experience suggests that instrumented spinal stabilization without fusion is an acceptable approach for patients with spinal metastatic disease.

Analysis of Four Scoring Systems for the Prognosis of Patients with Metastasis of the Vertebral Column

OBJECTIVE

Metastatic spinal diseases are common health problems and there is no consensus on the appropriate treatment of metastases in several conditions. Using clinical measures (e.g., survival time and functional status), prognosis prediction systems advise on the appropriate interventions. The aim of this article is to assess and compare 4 widely used scoring systems (revised Tokuhashi, Tomita, van der Linden, and modified Bauer scores) on a single-center cohort.

METHODS

A retrospective study was designed of 329 patients who were subjected to surgery because of metastatic spinal diseases. Subpopulations according to the classifications of the 4 scoring systems were identified. The overall survival was calculated with the Kaplan-Meier formula. The difference between the survival curves of subpopulations was analyzed with log-rank tests. The consistency rates for the 4 scoring systems are calculated as well.

RESULTS

The follow-up period was 8 years. The median survival time was 222 days. The overall survival of prognostic categories in 3 scoring systems was significantly different from each other, but we found no differences between the categories of the van der Linden system. In this cohort, the revised Tokuhashi system gave the best approximation for survival, with a mean predictive capability 60.5%.

CONCLUSIONS

The evaluation of 4 standard scoring systems showed that 3 were self-consistent, although none of systems was able to predict the survival in our cohort. Based on the predictive capability, the revised Tokuhashi system may provide the best predictions with careful examination of individual cases.

Oncological and functional results of the surgical treatment of vertebral metastases in patients with multiple myeloma"

Background

In nearly 30% of patients with myeloma, pathological fractures are found to occur in the spine. If the patients are not treated promptly and satisfactorily, the quality of their lives diminishes. Currently, the standard treatment for metastatic lesions of the spine is radiotherapy, but surgical intervention is becoming more frequent. It is very important to quickly identify metastases and implement surgical treatment before any fracture/s occur.

Methods

Over the period of 2010–2014 in our department, a total of 129 patients were treated for metastatic spinal myeloma. 73 patients underwent vertebroplasty and 56 patients were operated on through various methods. Indications for the surgery, its course, technique and outcome were subsequently evaluated. The majority of patients (76%) admitted for treatment, exhibited vertebral fractures. Most lesions were multiplace and involved the vertebral bodies. In 42% of the patients, radiological examinations showed symptoms of compression of the nervous structures, while clinical signs were observed in only 16% of the patients. The functional status of the patients was assessed using the Karnofsky scale, while pain intensity was measured in a VAS score, before and after the surgery. The oncological results were assessed as a survival rate and local recurrence rate.

Results

The average follow-up was conducted within 31 months (min 18, max 48). The patients after vertebroplasty survived 42 months, and the patients after surgery 23 months. Local recurrence of the disease was observed in 12 patients. In 10 patients, among a group of 21 with paresis, their neurological conditions improved. The average results of both their VAS score and Karnofsky performance score in patients after surgery was seen to have improved. Only sporadic postoperative complications after vertebroplasty and surgery were reported.

Conclusions

Early diagnosis of myeloma spine metastasis is essential to achieve the desired results of treatment. Vertebroplasty, as advised, should be performed as early as possible. Both the functional and oncological results after vertebroplasty are beneficial and the complication rates are low. Three relevant factors were found in our study: patient’s age over 65 years, initial diagnosis over 3 years and stage III of disease were related, significantly and statistically to survival.

Early developed ASD (adjacent segmental disease) in patients after surgical treatment of the spine due to cancer metastases

Background

The causes of ASD are still relatively unknown. Correlation between clinical status of patients and radiological MRI findings is of primary importance. The radiological classifications proposed by Pfirmann and Oner are most commonly used to assess intradiscal degenerative changes.

The aim of the study was to assess the influence of the extension of spine fixation on the risk of developing ASD in a short time after surgery.

Methods

A total of 332 patients with spinal tumors were treated in our hospital between 2010 and 2013. Of these patients, 287 underwent surgeries. A follow-up MRI examination was performed 12 months after surgical treatment. The study population comprised of 194 patients. Among metastases, breast cancer was predominant (29%); neurological deficits were detected in 76 patients. Metastases were seen in the thoracic (45%) and lumbar (30%) spine; in 25% of cases, they were of multisegmental character. Pathological fractures concerned 88% of the patients. Statistical calculations were made using the χ2 test. Statistical analysis was done using the Statistica v. 10 software. A p value <0.05 was accepted as statistically significant. The study population was divided on seven groups according to applied treatment.

Results

Clinical signs of ASD were noted in only seven patients. Two patients had symptoms of nerve root irritation in the lumbar spine. Twenty-two patients (11%) were diagnosed with ASD according to the MRI classifications by Oner, Rijt, and Ramos, while the more sensitive Pfirmann classification allowed to detect the disease in 46 patients (24%). Healthy or almost healthy discs of Oner type I correlated with the criteria of Pfirmann types II and III. The percentage of the incidence of ASD diagnosed 1 year after the surgery using the Pfirmann classifications was significantly higher than diagnosed according to the clinical examination.

Conclusions

The incidence of ASD in patients after spine surgeries due to cancer metastases does not differ between the study groups. ASD detectability based on clinical signs is significantly lower than ASD detectability based on MR images according to the system by Pfirrmann et.al. ASD risk increase among patients with multilevel fixation.

Transesophageal Bronchoscopic Ultrasound-Guided Fine-Needle Aspiration for Metastatic Vertebral Body Lesion

Malignant neoplasms frequently cause vertebral metastases. Traditionally, either image-guided percutaneous biopsy or open biopsy has been performed for sampling specimens for the definitive diagnosis. We herein report a case with suspected multiple metastases but unknown primary, who underwent endobronchial ultrasound-guided transbronchial needle aspiration for mediastinal lymph nodes with negative results by rapid onsite cytologic evaluation, followed by the transesophageal approach with the ultrasound bronchoscope for the vertebral body lesion at the same setting that provided a definitive diagnosis of metastatic hepatocellular carcinoma.

Metastases in the cervical spine from primary head and neck cancers: current concepts of diagnosis and management

Vertebral metastases from primary head and neck cancers are uncommon, and so there are no clear guidelines about management. The spinal cord can be compressed by a vertebral fracture or invasion of a tumour, and may present as an oncological and spinal emergency. The goals of treatment are to relieve pain and maintain neurological function. However, surgical treatments in this group of patients have not been defined, and primary operative treatment of spinal metastases remains controversial. Here we discuss their contemporary management. Surgical options should be considered for treatment to achieve stability of the spine, relieve pain, and preserve neurological function in certain cases.

Photodynamic therapy in spinal metastases: a qualitative analysis of published results

The current study was to perform qualitative comparison of photodynamic therapy (PDT), based on previously published articles on spinal disease distribution status before and after treatment. Spinal metastasis, the migration of primary cancer cells and establishment of secondary tumors in the spine. We electronically searched CENTRAL (The Cochrane Library 2012), MEDLINE, EMBASE, CINAHL and AMED (from their beginning to December 31, 2012) to identify published studies assessing the effectiveness of PDT in spinal metastases. Our inclusion criteria resulted in only 4 articles, all in mice models. Due to study limitations and sparse data, the quality of evidence for all outcomes was low. Our analyses shows that effects on stereological and mechanical properties observed at the 1-week time point post-PDT are maintained at a longer 6-week time point, with combined PDT + bisphosphonate treatment being the most beneficial in terms of bone enhancement. Additionally, the combination of PDT + radiation therapy also demonstrated significant increases in stereological parameters, suggesting that previous radiation therapy treatment does not preclude the bone-enhancing effects of PDT and in fact may be synergistic in the longer term. The bone-enhancing effects of PDT in combination with conventional treatments, and its ability to destroy metastatic human breast cancer cells within bone, present PDT as an attractive novel treatment for spinal metastasis. The positive results from these preclinical studies might motivate future clinical translation of PDT for spinal metastasis.

Detection of vertebral metastases: a meta-analysis comparing MRI, CT, PET, BS and BS with SPECT

OBJECTIVE

To perform a meta-analysis to compare the diagnostic value of magnetic resonance imaging (MRI), computed tomography (CT), positron emission tomography (PET), bone scintigraphy (BS) and BS with single-photon emission computed tomography (SPECT) in detecting vertebral metastases.

METHODS

Relevant original articles published from January 1995 to December 2015 were searched. Two reviewers independently extracted data. Software called "META-DiSc" was used to obtain pooled estimates of sensitivity, specificity, diagnostic odds ratio (DOR) and summary receiver operating characteristic (SROC) curves.

RESULTS

Twenty-three articles consisting of 33 studies fulfilled all inclusion criteria. On per-patient basis, for sensitivity, MRI = PET = SPECT > CT = BS ("=" indicated no significant difference, P > 0.05; ">" indicated significantly higher, P < 0.05). For specificity, MRI = CT = BS > SPECT > PET. For DOR, MRI > SPECT > BS > CT = PET. SROC curves for SPECT and MRI showed better diagnostic accuracy than others. On per-lesion basis, for sensitivity, PET = SPECT = MRI > BS > CT. For specificity, MRI = CT > PET = SPECT = BS. For DOR, MRI > SPECT > CT = PET > BS. SROC curves showed MRI had the best while CT had the lowest diagnostic accuracy.

CONCLUSION

For diagnosis of vertebral metastases, MRI was found to be the best modality and also better than other techniques on both per-patient and per-lesion basis.

"Quality of life of patients after surgical treatment of cervical spine metastases"

Background

Metastases of malignant neoplasms to the cervical spine are relatively rare. The most common symptom of metastatic disease is pain. Symptoms associated with roots damage or spinal cord compression indicate locally advanced disease. In a large number of patients, surgical treatment brings benefits such as pain reduction and improvement of the quality of life. Pain intensity, neurological status, and quality of patients’ lives are measured with the VAS, Frankel, and Karnofsky scales.

Methods

Symptoms of the disease, morphology of the metastasis and treatment outcomes were evaluated in 57 patients treated surgically because of metastases to the cervical spine over the period 2010–2014 in Brzozów. The morphology of the metastases was assessed on the basis of CT and MR examinations. Pre- and postoperative functional status of the patients was evaluated using Karnofsky scale. The intensity of pain was assessed with VAS and the neurological status was evaluated by using Frankel’s grades. Anterior approach was employed in 16 patients, posterior approach in 30 patients, and postero-anterior approach in 11 patients. The inter-group differences were evaluated using the U Mann–Whitney and Wilcoxon Matched Pairs test. All statistical analyses were performed by using Statistica 10. A value of P < 0.05 was considered statistically significant.

Results

The majority of patients suffered from pain associated with instability of the spine. Multi-level metastases were noted in 40 patients, while in 17 patients 1 vertebra was involved. In 51 patients the metastases caused pathological fractures of the vertebrae. The most common neurological complications was observed in patients with multi-level tumors and with pedicles involvement. After surgery patients functional status improved and pain intensity decreased. The best results (statistically significant) were observed in patients operated with anterolateral approach. Complications were scarce. Two patients required reoperation due to infection.

Conclusions

Surgical treatment of metastases to the cervical spine gives good outcomes and it ought to be a treatment of choice. Proper and multifaceted qualification of the patients for different treatments is of vital importance.

The Correspondence Between Magnetic Resonance Images and the Clinical and Intraoperative Status of Patients with Spinal Tumors

ABSTRACT INTRODUCTION

Surgical treatment of tumors, particularly metastases to the spine, has become increasingly common owing to the progress in anesthesiology and spinal surgery and greater detectability. The patients qualified for surgeries are those with mechanical pain, fracture or at risk of vertebral fracture or neurological complications. The basis for qualification for different types of surgeries is clinical and imaging examination, particularly MRI and CT. Qualification should always be multidisciplinary and requires understanding and knowledge of its most essential aspects. When carrying out imaging examinations, it is necessary to assess the size and the type of the tumor, taking into account of differential diagnosis. One should also consider the factors indicating spinal instability or the onset of neurological deficits. The criteria developed by Kostiuk-Weinstain and Taneichi are used for that purpose. The aim of the present study was to evaluate the correspondence between the most essential elements of clinical and MRI examination of the spine and the intraoperative status of patients with spinal tumors.

MATERIALS AND METHODS

We carried out prospective examination assessing the correspondence between the clinical status and MR images and the intraoperative spine. We introduced algorithm to describe the morphology of neoplastic lesions within the spine.

RESULTS

The information obtained from the clinical examination and the intraoperative status of the spine corresponded with the MRI examination with the exception of the assessment of neoplastic infiltration to soft tissues, dura mater and nerve roots. It was also found that there are no clear-cut MRI features allowing differentiation of metastatic lesions from primary tumors and osteitis. Furthermore, MRI examination does not allow for the assessment of the quality of bone tissue in the vicinity of the tumor.

Single-fraction versus multifraction spinal stereotactic radiosurgery for spinal metastases from renal cell carcinoma: secondary analysis of Phase I/II trials

OBJECTIVE The objective of this study was to compare fractionation schemes and outcomes of patients with renal cell carcinoma (RCC) treated in institutional prospective spinal stereotactic radiosurgery (SSRS) trials who did not previously undergo radiation treatment at the site of the SSRS. METHODS Patients enrolled in 2 separate institutional prospective protocols and treated with SSRS between 2002 and 2011 were included. A secondary analysis was performed on patients with previously nonirradiated RCC spinal metastases treated with either single-fraction (SF) or multifraction (MF) SSRS. RESULTS SSRS was performed in 47 spinal sites on 43 patients. The median age of the patients was 62 years (range 38-75 years). The most common histological subtype was clear cell (n = 30). Fifteen sites underwent surgery prior to the SSRS, with laminectomy the most common procedure performed (n = 10). All SF SSRS was delivered to a dose of 24 Gy (n = 21) while MF regiments were either 27 Gy in 3 fractions (n = 20) or 30 Gy in 5 fractions (n = 6). The median overall survival duration for the entire cohort was 22.8 months. The median local control (LC) for the entire cohort was 80.6 months with 1-year and 2-year actuarial LC rates of 82% and 68%, respectively. Single-fraction SSRS correlated with improved 1- and 2-year actuarial LC relative to MF SSRS (95% vs 71% and 86% vs 55%, respectively; p = 0.009). On competing risk analysis, SF SSRS showed superior LC to MF SSRS (subhazard ratio [SHR] 6.57, p = 0.014). On multivariate analysis for LC with tumor volume (p = 0.272), number of treated levels (p = 0.819), gross tumor volume (GTV) coverage (p = 0.225), and GTV minimum point dose (p = 0.97) as covariates, MF SSRS remained inferior to SF SSRS (SHR 5.26, p = 0.033) CONCLUSIONS SSRS offers durable LC for spinal metastases from RCC. Single-fraction SSRS is associated with improved LC over MF SSRS for previously nonirradiated RCC spinal metastases.

Electrochemotherapy to Metastatic Spinal Melanoma: A Novel Treatment of Spinal Metastasis?

STUDY DESIGN

Preliminary report of new antitumor treatment.

OBJECTIVE

To evaluate the effectiveness of electrochemotherapy as a novel treatment of spinal metastasis.

SUMMARY OF BACKGROUND DATA

Electrochemotherapy is a new antitumor treatment that combines systemic bleomycin with electric pulses delivered locally at the tumor site. These electric pulses permeabilize cell membranes in the tissue, allow bleomycin delivery diffusion inside the cells, and increase bleomycin cytotoxicity. Previous clinical studies have demonstrated the effectiveness of electrochemotherapy in the treatment of several primary and metastatic solid tumors.

METHODS

Treatment planning for electrode positioning and electrical pulse parameters was prepared for 4 needle electrodes. Mini-open surgery with a left L5 laminectomy was performed to introduce the eletrodes. The patient was treated according to the established Electrochemotherapy Protocol with Bleomycin. Clinical efficacy of electrochemotherapy was evaluated according to a visual analog scale of pain, Oswestry Disability Index 2.0, the Karnofsky Performance Scale, and Response Evaluation Criteria in Solid Tumors.

RESULTS

The assessed follow-up period was 48 months after the electrochemotherapy procedure. Neither serious electrochemotherapy-related adverse events, nor bleomycin toxicity were reported. Overall improvement in pain according to Oswestry Disability Index 2.0 and Karnofsky Performance Scale outcomes was better.

CONCLUSION

Our case represents, to our knowledge, the first one to test the potential role of electrochemotherapy as treatment of spinal metastasis. Electrochemotherapy allowed a successful treatment of metastatic spinal melanoma. However, we believe that there is a strong scientific rationale to support the potential utility of electrochemotherapy as a novel treatment of spinal metastasis, regardless of the histological types.

LEVEL OF EVIDENCE

5.

Intensity-modulated radiotherapy versus proton radiotherapy versus carbon ion radiotherapy for spinal bone metastases: a treatment planning study

Outcomes for selected patients with spinal metastases may be improved by dose escalation using stereotactic body radiotherapy (SBRT). As target geometry is complex, we compared SBRT plans using step‐and‐shoot intensity‐modulated radiotherapy (IMRT), carbon ion RT, and proton RT. We prepared plans treating cervical, thoracic, and lumbar metastases for three different techniques — IMRT, carbon ion, and proton plans — to deliver a median single 24 Gy fraction such that at least 90% of the planning target volume (PTV) received more than 18 Gy and were compared for PTV coverage, normal organ sparing, and estimated delivery time. PTV coverage did not show significant differences for the techniques, spinal cord dose sparing was lowered with the particle techniques. For the cervical lesion spinal cord maximum dose, dose of 1% (D1), and percent volume receiving 10 Gy (V10Gy) were 11.9 Gy, 9.1 Gy, and 0.5% in IMRT. This could be lowered to 4.3 Gy, 2.5 Gy, and 0% in carbon ion planning and to 8.1 Gy, 6.1 Gy, and 0% in proton planning. Regarding the thoracic lesion no difference was found for the spinal cord. For the lumbar lesion maximum dose, D1 and percent volume receiving 5 Gy (V5Gy) were 13.4 Gy, 8.9 Gy, and 8.9% for IMRT; 1.8 Gy, 0.7 Gy, and 0% for carbon ions; and 0 Gy,<0.01 Gy, and 0% for protons. Estimated mean treatment times were shorter in particle techniques (6–7 min vs. 12–14 min with IMRT). This planning study indicates that carbon ion and proton RT can deliver high‐quality PTV coverage for complex treatment volumes that surround the spinal cord.

PACS number: 87.55.dk

Role of Magnetic Resonance Imaging in Differentiating Spondylitis from Vertebral Metastasis

Study Design

Observational analytic design with a cross-sectional approach.

Purpose

To analyze the suitability of magnetic resonance imaging (MRI) in distinguishing radiology images with a corresponding delineation of spondylitis and vertebral metastasis confirmed by histology results.

Overview of Literature

MRI is an accurate modality for assessing vertebrae and their disorders. Infections and metastasis are most commonly found in the vertebrae. It is difficult to differentiate between these two disorders both clinically and radiographically, particularly in atypical cases.

Methods

McNemar statistical test was used to analyze the data. Samples were chosen using the consecutive method. There were 35 samples (14 males and 21 females), consisting of 22 samples of spondylitis and 13 samples of metastasis confirmed on histology examination.

Results

Nineteen (86%) out of the 22 samples of histological spondylitis were diagnosed as having spondylitis on MRI, whereas all 13 samples of metastasis were 100% accurately diagnosed on MRI.

Conclusions

There was no statistically significant difference between diagnostic radiology using MRI and histological diagnosis with a p=0.250 (p>0.05). In this respect, MRI was more precise in diagnosing metastasis. Typical MRI description of spondylitis was the involvement of anterior vertebrae and components of intervertebral discs, stiffening of discs, paravertebral abscess, and involvement of the vertebral segment sequence. Typical MRI delineation of metastasis was involvement of the anterior posterior vertebral component, paravertebral mass, and skip lesions.

Management of metastatic spinal column neoplasms--an update

The increased survival of cancer patients due to the improvement and advancement of therapeutic modalities has promoted progressive increase in the prevalence of metastatic tumors of the spine, making it important for healthcare professionals to acquire knowledge in the field. Spinal column metastases are usually secondary to malignant neoplasm of the breast, lung and prostate, male gender being the most often affected and pain being the initial symptom in 90% of patients. It is estimated that 30-90% of terminally ill patients with cancer have metastases at some spinal column segment. Clinical history, physical and neurological assessments are critical to determine the degree and extent of the lesion, and therefore choose the appropriate imaging method to be requested. This study aims to perform a review and didactic description of the main aspects related to the physiopathology, diagnosis and treatment of this disease.

Separation surgery for spinal metastases: effect of spinal radiosurgery on surgical treatment goals

BACKGROUND

The treatment of epidural spinal cord compression due to metastatic cancer represents an important clinical challenge. The NOMS (neurologic, oncologic, mechanical, and systemic) framework facilitates the determination of the optimal combination of systemic, radiation, and surgical therapies for individual patients. Spinal stereotactic radiosurgery (SRS) is an effective and safe modality for achieving durable control of local disease. Integrating SRS into the postoperative treatment plan allows surgical goals to be modified, thus decreasing the extent of tumor resection required.

METHODS

Separation surgery is indicated for patients with spinal cord compression secondary to solid tumor metastases. During separation surgery, the spinal column is stabilized and the epidural tumor is resected without requiring significant vertebral body resection.

RESULTS

Tumor separation from the spinal cord allows patients to undergo postoperative SRS.

CONCLUSIONS

The combination of separation surgery and high-dose hypofractionated or single-fraction SRS results in high local tumor control at 1 year and is an effective palliative paradigm for this patient population.

Vertebral metastases from intracranial meningioma

Meningioma rarely gives rise to metastases outside the brain and meninges. We report here a case of a patient who was treated for anaplastic brain meningioma with surgery and fractionated radiation therapy without any recurrence until 5 years after the operation, when she developed vertebral metastases.

Metastatic bone tumors: Analysis of factors affecting prognosis and efficacy of CT and 18F-FDG PET-CT in identifying primary lesions

We analyzed the prognostic factors in patients with metastatic bone tumors and evaluated the efficacy of different modalities in identifying the primary lesions. A total of 145 patients with bone metastases who attended the orthopaedic outpatient clinic were included in this study. The most frequent site of bone metastases was the spine. The primary tumor type was differently distributed between patients with a known primary tumor at the first visit and those with an unknown primary lesion. The number of breast cancer cases was statistically significantly lower in the primary-unknown group. However, the number of myeloma cases was significantly higher in the primary-unknown group. Survival was significantly lower in the skeletal-related events (SREs) compared to that in the non-SREs group. Furthermore, survival was significantly worse in patients with a performance status (PS) of ≥2 compared to those with a PS of ≤1 and neurological complications occurred statistically more often in the group with worse PS (≥2). Survival rates were significantly lower in the non-spinal compared to those in the spinal metastatic group. Since the majority of breast cancer patients presented with metastasis in the spine, a breast cancer origin was a positive prognostic factor in patients with spinal metastases. Although there were no significant differences between computed tomography (CT) and ¹⁸F-fluoro-2-deoxyglucose (¹⁸F-FDG) positron emission tomography (PET)-CT in detecting primary lesions, CT may be the first choice due to its feasibility. In conclusion, lung cancer, SREs and worse PS were adverse prognostic factors for patients with bone metastasis. In addition, CT scans may be more useful for determining the primary lesion of a bone metastasis compared to ¹⁸F-FDG PET-CT in a timelier manner.

The benefits of photodynamic therapy on vertebral bone are maintained and enhanced by combination treatment with bisphosphonates and radiation therapy

Photodynamic therapy (PDT) has been shown to ablate tumors within vertebral bone and yield short-term improvements in vertebral architecture and biomechanical strength, in particular when combined with bisphosphonate (BP) treatment. Longer-term outcomes of PDT combined with current treatments for skeletal metastases are essential to understand its therapeutic potential. The objective of this study is to evaluate the response of vertebrae to PDT after a longer (6-week) time period, alone and combined with previous BP or radiation treatment (RT). Sixty-three female rnu/rnu rats were randomized to six treatment groups: untreated control, BP-only, RT-only, PDT-only, combined BP + PDT and combined RT + PDT. L2 vertebrae were structurally analyzed through µCT-based analysis, axial compressive load-to-failure testing and histological analysis of morphology, osteoid formation and osteoclast activity. Combined BP + PDT treatment yielded the largest improvements in bone architecture with combined RT + PDT treatment yielding similar findings, but of a lesser magnitude. Mechanically, ultimate force and stress were correlated to stereological parameters that demonstrated a positive structural effect from combinatory treatment. Increased osteoid formation was observed in both combination therapies without any significant differences in osteoclast activity. Overall, multimodality treatment demonstrated a sustained positive effect on vertebral structural integrity, motivating PDT as a minimally-invasive adjuvant treatment for spinal metastases.