An overview of the tumors affecting the spine-inside to out

Spine tumors may arise within or surrounding the spinal cord and/or vertebral column. Spinal tumors can be benign or malignant. Based on their epicenter, they may be classified as intradural-intramedullary, intradural-extramedullary, or extradural. Of these, extradural lesions are the most common, and are typically metastatic. Primary bone tumors of the spinal column comprise 5% of all primary skeletal tumors. The majority of primary spinal column tumors are benign, with malignant tumors comprising only 20%. Overall, spine metastases are the most common malignant spine tumor, and these usually arise from primaries such as lung, breast, and prostate cancers. The advent of improved systemic therapies leading to improved survival and the frequent use of imaging has positioned metastatic spine disease as the new epidemic in oncology. For spine tumors, establishing the correct diagnosis is heavily reliant on magnetic resonance imaging and histological confirmation. In this review, we will provide an overview of the epidemiology, radiological and histopathological features, and the natural history of key primary (benign and malignant) spinal cord and column tumors and metastatic spine tumors. Treatment principles for primary spinal cord or column tumors are aimed toward curative resection, whereas palliative resection forms the treatment principle for most metastatic tumors.

INCIDENCE OF SPINAL CANCER IN A TERTIARY CARE HOSPITAL IN MEXICO

ABSTRACT Objective To determine the incidence of primary malignant bone tumors of the spine in a High Specialty Orthopedics and Traumatology Medical Unit. Methods Review study. The study included patients receiving benefits from the Mexican Social Security Institute of all ages and both sexes with malignant spinal bone tumors during the period from 2010 to 2017. The descriptive statistics used were central tendency measures and dispersion in the SPSS v. 22 program from IBM. The results are presented in tables and figures. Results There were 107 patients, 56 (52.34%) men, 51 (47.66%) women with a mean age of 59.75 + 10.76 years (minimum 35, maximum 88). There were 46,840 hospital discharges during the period, for an annual average of 5,855 and a monthly average of 487.91. Of the 107 study cases, 78 (72.89%) were in the lumbosacral, 15 (14.01%) in the cervical, and 14 (13.08%) in the thoracic region. The incidence for the period was 1.9/1000 discharges, 1.38in 2010 increasing to 2.32 in 2017. Conclusions The behavior of primary malignant spinal tumors has increased its presentation from 2010 to 2017 . Level of evidence III; Non-analytical, descriptive study.

Neoadjuvant denosumab for the treatment of a sacral osteoblastoma

PURPOSE

To present a case of aggressive sacral osteoblastoma (OB) treated with neoadjuvant denosumab therapy and en bloc resection.

METHODS

Case report of a 14-year-old male with an aggressive OB affecting the superior articular process of the left first sacral segment. The lesion was lytic and metabolically active and involved the left-sided posterior elements of S1-S3 with extension into the spinal canal, affecting the left S1, S2, S3, S4 and S5 nerve roots. He was treated for 1 month with neoadjuvant denosumab followed by en bloc resection.

RESULTS

Denosumab therapy caused regression of the tumour and converted the diffuse infiltrative mass into a well-defined solid (osteoma-like) structure, aiding surgical resection and preserving the S1, S4 and S5 nerve roots. Histologically, the treated lesion showed abundant sclerotic woven bone and osteoblasts with absence of osteoclasts.

CONCLUSIONS

A short course of denosumab caused tumour regression, ossification and conversion of an aggressive OB into a sclerotic, well-defined lesion thus aiding surgical resection and preservation of neural structures. Neoadjuvant therapy reduced osteoclast numbers but PET showed that the lesion remained FDG avid post-therapy.

Surgical management of spinal osteoblastomas

OBJECTIVE Osteoblastoma is a rare primary benign bone tumor with a predilection for the spinal column. Although of benign origin, osteoblastomas tend to behave more aggressively clinically than other benign tumors. Because of the low incidence of osteoblastomas, evidence-based treatment guidelines and high-quality research are lacking, which has resulted in inconsistent treatment. The goal of this study was to determine whether application of the Enneking classification in the management of spinal osteoblastomas influences local recurrence and survival time. METHODS A multicenter database of patients who underwent surgical intervention for spinal osteoblastoma was developed by the AOSpine Knowledge Forum Tumor. Patient data pertaining to demographics, diagnosis, treatment, cross-sectional survival, and local recurrence were collected. Patients in 2 cohorts, based on the Enneking classification of the tumor (Enneking appropriate [EA] and Enneking inappropriate [EI]), were analyzed. If the final pathology margin matched the Enneking-recommended surgical margin, the tumor was classified as EA; if not, it was classified as EI. RESULTS A total of 102 patients diagnosed with a spinal osteoblastoma were identified between November 1991 and June 2012. Twenty-nine patients were omitted from the analysis because of short follow-up time, incomplete survival data, or invalid staging, which left 73 patients for the final analysis. Thirteen (18%) patients suffered a local recurrence, and 6 (8%) patients died during the study period. Local recurrence was strongly associated with mortality (relative risk 9.2; p = 0.008). When adjusted for Enneking appropriateness, this result was not altered significantly. No significant differences were found between the EA and EI groups in regard to local recurrence and mortality. CONCLUSIONS In this evaluation of the largest multicenter cohort of spinal osteoblastomas, local recurrence was found to be strongly associated with mortality. Application of the Enneking classification as a treatment guide for preventing local recurrence was not validated.

Disparities in reportable quality metrics by insurance status in the primary spine neoplasm population

BACKGROUND CONTEXT

The Centers for Medicare and Medicaid Services (CMS) defines "adverse quality events" as the incidence of certain complications such as postsurgical hematoma or iatrogenic pneumothorax during an inpatient stay. Patient safety indicators (PSI) are a means to measure the incidence of these adverse events. When adverse events occur, reimbursement to the hospital decreases. The incidence of adverse quality events among patients hospitalized for primary spinal neoplasms is unknown. Similarly, it is unclear what the impact of insurance status is on adverse care quality among this patient population.

PURPOSE

We aimed to determine the incidence of PSI among patients admitted with primary spinal neoplasms, and to determine the association between insurance status and the incidence of PSI in this population.

STUDY DESIGN

This is a retrospective cohort study.

PATIENT SAMPLE

We included all patients, 18 years and older, in the Nationwide Inpatient Sample (NIS) who were hospitalized for primary spine neoplasms from 1998 to 2011.

OUTCOME MEASURES

Incidence of PSI from 1998 to 2011 served as outcome variable.

METHODS

The NIS was queried for all hospitalizations with a diagnosis of primary spinal neoplasm during the inpatient episode from 1998 to 2011. Incidence of PSI was determined using publicly available lists of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. Logistic regression models were used to determine the effect of primary payer status on PSI incidence. All comparisons were made between privately insured patients and Medicaid or self-pay patients.

RESULTS

We identified 6,095 hospitalizations in which a primary spinal neoplasm was recorded during the inpatient episode. We excluded patients younger than 18 years and those with "other" or "missing" primary insurance status, leaving 5,880 patients for analysis. After adjusting for patient demographics and hospital characteristics, Medicaid or self-pay patients had significantly greater odds of experiencing one or more PSI (odds ratio [OR] 1.81 95% confidence interval [CI] 1.11-2.95) relative to privately insured patients.

CONCLUSIONS

Among patients hospitalized for primary spinal neoplasms, primary payer status predicts the incidence of PSI, an indicator of adverse health-care quality used to determine hospital reimbursement by the CMS. As reimbursement continues to be intertwined with reportable quality metrics, identifying vulnerable populations is critical to improving patient care.

Radiofrequency ablation of spinal osteoid osteoma: a prospective study

OBJECTIVE Surgery has been considered the standard treatment for spinal osteoid osteomas that are refractory to analgesic agents. Radiofrequency ablation (RFA) is a less invasive technique with established efficiency for the treatment of peripheral osteoid osteomas. The main objectives of this study are to evaluate the safety of RFA based on the results of a previous experimental study in rats conducted in the authors' laboratory and to identify its short- and long-term efficiency in the treatment of spinal osteoid osteomas. METHODS Between March 2009 and July 2016, 8 consecutive patients with spinal osteoid osteomas were enrolled in the study and underwent 9 CT-guided RFA procedures. All patients presented with spinal pain (median preoperative visual analog scale [VAS] score 7.55, range 6-8.8) predominantly during the night, and they all had normal neurological examination results before the procedure. Pain (according to the VAS score) and neurological status were reassessed immediately before discharge, with further follow-up at 1, 6, and 12 months after the procedure. At the final follow-up, VAS score, neurological examination, patient satisfaction, and a radiological control (CT scan) were documented (median 48 months, range 12-84 months). VAS scores before and after the procedure were compared during the 3 days before surgery (D0), on the day of the surgery, Day 1 (D1), and at the final follow-up. RESULTS No neurological deficit was documented following the procedure or at the final follow-up. A statistically significant reduction in the VAS score was observed on Day 1 (mean 2.56 ± 0.68, p = 0.005) compared with D0. At the final follow-up, all patients reported a VAS score of 0 and a satisfaction rate of 100%. Only 1 patient had recurrent symptoms (pain, VAS score 8.1) 6 months after the initial RFA. A second procedure was performed, and the patient was subsequently symptom free at the final follow-up. CT scanning performed in all patients (12-84 months post-RFA) showed residual sclerosis in 4 patients and complete resolution of the radiological lesion in the remaining 4 patients. CONCLUSIONS CT-guided RFA appears to be a safe and effective method for the management of spinal osteoid osteoma and can be safely performed for lesions close to the dura or exiting nerve root based on the motor response threshold testing performed during the procedure. It should be considered the treatment of choice for spinal osteoid osteomas refractory to conservative treatment, thus avoiding more aggressive spinal approaches with subsequent potential morbidity.

Management of spinal giant cell tumors

BACKGROUND CONTEXT

Spinal giant cell tumors (SGCT) remain challenging tumors to treat. Although advancements in surgical techniques and adjuvant therapies have provided new options for treatment, evidence-based algorithms are lacking.

PURPOSE

This study aims to review the peer-reviewed literature that addresses current treatment options and management of SGCT, to produce an evidence-based treatment algorithm.

STUDY DESIGN/SETTING

A systematic review was performed.

METHODS

Articles published between January 1, 1970 and March 31, 2015 were selected from PubMed and EMBASE searches using keywords "giant cell tumor" AND "spine" AND "treatment." Relevant articles were selected by the authors and reviewed.

RESULTS

A total of 515 studies were identified, of which 81 studies were included. Complete surgical resections of SCGT resulted in the lowest recurrence rates. However, morbidity of en bloc resections is high and in some cases, surgery is not possible. Intralesional resection can be coupled with adjuvant therapies, but evidence-based algorithms for use of adjuvants remain elusive. Several recent advancements in adjuvant therapy may hold promise for decreasing SGCT recurrence, specifically stereotactic radiotherapy, selective arterial embolization, and medical therapy using denosumab and interferon.

CONCLUSIONS

Complete surgical resection of SGCT should be the goal when possible, particularly if neurologic impairment is present. Denosumab holds promise as an adjuvant and perhaps stand-alone therapy for SGCT. Spinal giant cell tumors should be approached as a case-by-case problem, as each presents unique challenges. Collaboration of spine surgeons, radiation oncologists, and medical oncologists is the best practice for treating these difficult tumors.

Eosinophilic granuloma of the sacrum treated with radiation therapy: a case report

BACKGROUND CONTEXT

Eosinophilic granulomas (EGs) of the sacrum have been reported in fewer than 10 patients. Treatment algorithms for these tumors remain poorly defined; there are no reports of treating solitary sacral EG with radiation therapy (RT).

PURPOSE

This study aimed to describe the presentation, treatment, and outcome of sacral EG in an adult patient with intractable pain and radiculopathy, treated in a novel fashion with RT.

STUDY DESIGN/SETTING

The study design was a case report from a tertiary cancer referral center.

METHODS

Patient records, imaging, and pathology were reviewed.

RESULTS

A 35-year-old man received 20 Gy of radiation to his S1 EG lesion. He subsequently developed vertebra plana of S1 causing symptomatic L5-S1 stenosis, but 15 months after RT treatment was free of pain or tumor recurrence.

CONCLUSION

Radiation therapy is an effective treatment option for sacral EG causing severe axial pain and neural impingement.

The valuation of using FDG PET-CT in detecting osteoid osteoma of the cervical spine

STUDY DESIGN

Osteoid osteomas (OOs) are bone tumors that rarely occur in the cervical spine. The current study is a retrospective analysis on 10 patients who were diagnosed with this rare spinal bone tumor. We have excised OOs of the cervical spine with the use of FDG Positron emission tomography-computed tomography (PET-CT) for preoperative diagnosis.

OBJECTIVE

With the help of the FDG PET-CT, we can confidently remove the nidus of the OOs, while minimize iatrogenic injury of the surrounding normal bone elements, and preserve the stability of the cervical spine.

SUMMARY OF BACKGROUND DATA

OO of the cervical spine is frequently located at the nerve root adjacent to the vertebral artery, spinal cord. PET-CT is a sensitive tool with applications in the detection of bone lesions, especially in patients with difficult diagnosis or continuing misdiagnosis of tumors.

MATERIALS AND METHODS

Ten patients (8 male and 2 female patients) underwent surgery for tumor removal using PET-CT in our department. Various diagnostic imaging modalities including x-ray, magnetic resonance imaging, CT, bone scintigraphy, and PET-CT were used. PET-CT scan results were measured using standard uptake value. (The size of the cases series was from 4×5 mm to 12×15 mm.) Pain was evaluated using the visual analogue score. Clinical outcome was evaluated immediately postoperatively and at a mean follow-up of 49.8±0.2 months (range, 7-92 mo).

RESULTS

All tumors were successfully diagnosed with the use of PET-CT. The average standard uptake value was 2.7±0.1 (range, 2.0-3.4). The nidus of the OO was detected and removed, and the peripheral elements were preserved. The visual analogue score was 8.1±0.1 preoperation, and it significantly decreased to 2.5±0.3 (P<0.01) postoperation and 0.2±0.1 (P<0.01) at the final visit. Immediately after surgery, the patients were relieved of their pain symptoms. There was no injury of the vertebral artery, leakage of cerebrospinal fluid, infectious complications, and neurological injury during the procedure.

CONCLUSIONS

It is valuable of using of PET-CT to diagnose OOs of the cervical vertebra. Subsequently, it is a good way that helps us in efficient removal of the OOs completely.

Adult onset asynchronous multifocal eosinophilic granuloma of bone: an 11-year follow-up

Multifocal eosinophilic granuloma (EG) is a rare observation within the spectrum of histiocytosis X, generally described in children. We report the case of a 33-year-old man with multifocal EG showing an asynchronous evolution of bone lesions during a follow-up of 11 years. We also present the therapeutic approach chosen for this patient and the repeated magnetic resonance imaging (MRI) examinations used to monitor the disease with a final favorable outcome.

Fibrohistiocytoma combined with an aneurysmal bone cyst at T7 in a 63-year-old woman

We present a case of spinal tumor, with fibrohistiocytoma combined with aneurysmal bone cyst (ABC) at the pedicle and transverse process of T7 in a 63-year-old female. ABC is a rare skeletal tumor and spinal ABC is extremely rare. Fibrohistiocytoma is a type of primary benign bone tumor. ABC is also a rare bone tumor that most often occurs in the pelvis. The combined lesion of two primary bone benign tumors is relatively rare in clinic. In addition, fibrohistiocytoma and ABC are widely confused with other giant cell containing tumors of the bone. X-rays, magnetic resonance imaging (MRI) and positron emission tomography-computed tomography (PET-CT) scans were performed and assessed. Finally, the diagnosis was confirmed by pathological tests. The patient underwent surgery and had an extremely good recovery. The correct diagnosis of a spine tumor is important when determining the surgical procedure.