A Novel and Reproducible Classification of Cervical Dumbbell Tumors to Inform Surgical Approach and Reconstruction Techniques

STUDY DESIGN

A retrospective case series.

OBJECTIVE

This study developed a novel classification system based on imaging and anatomy to select optimal surgical approaches and reconstruction strategies to achieve total resection of cervical dumbbell tumors and restore spinal stability.

SUMMARY OF BACKGROUND DATA

Total resection is necessary to decrease the recurrence rate of cervical dumbbell tumors. Previous cervical dumbbell tumor classifications are insufficient for determining surgical strategies; therefore, a practical classification is needed.

MATERIALS AND METHODS

This study included 295 consecutive patients with cervical dumbbell tumors who underwent total surgical resection. A novel classification of cervical dumbbell tumors was developed based on magnetic resonance imaging and computed tomography. Continuous variables were expressed as mean±SD and were compared using an unpaired two-tailed Student t test. The χ 2 test or the Fisher exact test was used for categorical variables. Kendall's W test assessed three independent raters' inter-rater and intrarater reliabilities on 140 cervical dumbbell tumors.

RESULTS

The inter-rater and intrarater consistency coefficient was 0.969 (χ 2 =404.3, P <0.001) and 0.984 (χ 2 =273.7, P <0.001). All patients with type I and II tumors underwent single-posterior surgeries to achieve total resection. Of the patients in this study, 86.1%, 25.9%, 75.9%, and 76.9% underwent posterior surgeries for types IIIa, IIIb, IVa, and V tumors, respectively. All patients with type IVb tumors underwent a combined anterior and posterior approach. Posterior internal fixation was used for all patients in posterior surgery. Anterior reconstruction was applied for patients with type IVb tumors (20/20, 100%) and some with type V tumors (3/13, 23.1%). The mean follow-up duration was 93.6±2.6 months. A recurrence was observed in 19 (6.4%) patients.

CONCLUSION

The authors describe a novel classification system that is of practical use for planning the complete resection of cervical dumbbell tumors.

[Diagnostics and treatment of benign spinal tumors]

Benign tumors of the spine are rare and may lead to unspecific back pain. The classification of the lesion is typically achieved with a combination of imaging techniques (MRI and CT scans) and, in some cases, a histological sampling to allow differentiation from malignant processes. Both open and interventional (CT guided) biopsies are possible, depending on the localization of the tumor. Treatment strategies are diverse, require an interdisciplinary approach, and include operative and interventional procedures. The following article gives an overview of the most important benign tumors of the spine, the typical features in imaging, and treatment strategies.

An independent evaluation on the interobserver reliability and intraobserver reproducibility of Toyama classification system for cervical dumbbell tumors

Dumbbell tumors can not only cause the compression of cervical cord and nerve root, but also invade the important structures and the surrounding organs, causing great harm to the patient. Toyama classification that is commonly used has not been evaluated and still requires independent validation.The objectives of this study were to evaluate and analyze the interobserver reliability and intraobserver reproducibility of Toyama classification system, explore the differences, discover the shortages, and evaluate the clinical value for diagnosis.One hundred sixty-five consecutive patients of a cervical dumbbell tumor with complete clinical and radiologic data were enrolled. Six surgeons determined the classification according to Toyama system. The classification was repeated 12 weeks later. Correlation coefficient (ICC) and kappa coefficient (κ) test were used to determine interobserver reliability and intraobserver reproducibility.The interobserver reliability for Toyama classification was moderate with a value of 0.432. The interobserver reproducibility for Toyama classification was moderate with a value of 0.608.The Toyama classification has landmark value in clinical practice, but it is a relatively cumbersome system. This study shows that it has low reliability and reproducibility. Accordingly, surgical management of the resection of dumbbell cervical tumors raises several problems, including preservation of the cervical nerve root, control of the vertebral artery, and maintenance of spine. There is a need to optimize the classification in the future.

MRI findings in intraspinal mature teratoma

AIM

To characterise and evaluate magnetic resonance imaging (MRI) images for their clinical value in diagnosing and assessing intraspinal mature teratoma.

MATERIALS AND METHODS

MRI images obtained from eight patients with a histopathologically verified intraspinal mature teratoma were analysed retrospectively regarding tumour location, size, and margins. Additionally, the signal intensity and enhancement pattern on MRI and other associated malformations were also assessed.

RESULTS

Three cases that contained fatty tissue showed markedly heterogeneous hyperintense signalling on T1-weighted images, and mixed hyperintense and hypointense signalling on T2-weighted images and fat-suppression sequences. All three of those cases showed an irregular peripheral fatty tissue signal, and one case showed additional patches of an interspersed calcification signal. The remaining five cases without fatty tissue displayed heterogeneous hyperintense signalling on T1-weighted images and T2-weighted images, and also on fat-suppression sequences. Four of the five cases showed additional patches of interspersed nodular calcification signals. Contrast-enhanced MRI images showed only slight enhancement (n=3).

CONCLUSIONS

MRI is regarded as the reference standard diagnostic technique to reveal the location of teratomas and the degree of spinal cord involvement. In most cases, MRI provides accurate anatomical and histological information, which is necessary for patients with suspected intraspinal mature teratoma.

[Clinical classification and selection of surgical approaches for cervical spinal dumbbell tumors]

OBJECTIVE

To explore the clinical classification and selection of surgical approaches for cervical spinal dumbbell tumors.

METHODS

The clinical data of 87 patients with cervical spinal dumbbell tumors undergoing surgical operations from January 2005 to December 2012 at our hospital were analyzed retrospectively. According to the size of inner and outer parts of tumors and the presence or absence of spinal bone damage, the cervical spinal dumbbell tumors were divided into 4 types of intraspinal predominant (I, n = 48), extraspinal predominant (II, n = 1), intrapinal and extraspinal without damage of spinal bone (III, n = 15) and intrapinal and extraspinal type with damage of spinal bone (IV, n = 7). Different surgical approaches were selected on the basis of tumor classification: posterior median-hemilamina approaches for type I tumors, lateral-muscle gap approaches for type II tumors, ateral-muscle gap-hemilamina or lateral-muscle gap-posterior median-hemilamina approaches for type III tumors, posterior far lateral-muscle gap-hemilamina or posterior median-muscle gap-hemilamina approaches plus posterior occipital cervical or cervical spinal bone graft fusion and internal fixation for type IV tumors.

RESULTS

Among them, 83 cases underwent total resection and another 4 subtotal resection in one-stage operation. The postoperative follow-up period had a range of 9 months to 6 years (mean, 3.2 years). There was no recurrence of tumors for total resection and 1 case of tumor recurrence for subtotal resection. During the follow-up period, the clinical manifestations of 85 patients improved while another 2 deteriorated. And there was no occurrence of spinal deformity.

CONCLUSION

Clinical classification of cervical spinal dumbbell tumor plays an important guiding role in the selection of surgical approaches. Adopting appropriate surgical approaches based on tumor type can not only improve the rate of total resection of tumor but also reduce the incidence of postoperative spinal deformity.

The NOMS framework: approach to the treatment of spinal metastatic tumors

BACKGROUND

Spinal metastases frequently arise in patients with cancer. Modern oncology provides numerous treatment options that include effective systemic, radiation, and surgical options. We delineate and provide the evidence for the neurologic, oncologic, mechanical, and systemic (NOMS) decision framework, which is used at Memorial Sloan-Kettering Cancer Center to determine the optimal therapy for patients with spine metastases.

METHODS

We provide a literature review of the integral publications that serve as the basis for the NOMS framework and report the results of systematic implementation of the NOMS-guided treatment.

RESULTS

The NOMS decision framework consists of the neurologic, oncologic, mechanical, and systemic considerations and incorporates the use of conventional external beam radiation, spinal stereotactic radiosurgery, and minimally invasive and open surgical interventions. Review of radiation oncology and surgical literature that examine the outcomes of treatment of spinal metastatic tumors provides support for the NOMS decision framework. Application of the NOMS paradigm integrates multimodality therapy to optimize local tumor control, pain relief, and restoration or preservation of neurologic function and minimizes morbidity in this often systemically ill patient population.

CONCLUSION

NOMS paradigm provides a decision framework that incorporates sentinel decision points in the treatment of spinal metastases. Consideration of the tumor sensitivity to radiation in conjunction with the extent of epidural extension allows determination of the optimal radiation treatment and the need for surgical decompression. Mechanical stability of the spine and the systemic disease considerations further help determine the need and the feasibility of surgical intervention.

[Clinico-pathological and molecular aspects of diagnostic and prognostic value in gliomas]

INTRODUCTION

Diffuse infiltrative gliomas, the most common primary brain tumours, account for almost 80% of malignant brain tumours. 60-70% of gliomas are astrocytic and over 80% of these tumours is considered high grade malignancy (grade III and IV) according to current World Health Organization classification. Infiltrating gliomas include diffuse astrocytomas, oligodendrogliomas and oligoastrocytomas.

AIM

To review the clinical and histological features of cerebral gliomas, and molecular alterations that add relevant information for novel approaches in diagnosis, prognosis and treatment.

DEVELOPMENT

The current gold standard diagnosis of these tumours relies on histopathological classification, which provides a grading of malignancy as a predictor of biological behaviour. However emerging molecular abnormalities have been discovered in the last years and these molecular changes are playing an increasingly prominent role as predictive biomarkers or in the development of diagnostic and prognostic. Now the neuropathologist is in crossroads between pathology and molecular biology and he plays a significant role in implementation of treatments and/or clinical trials.

CONCLUSIONS

The study of proteomics and molecular biomarkers should complement the histopathological analysis and sometimes allows to determine direct or indirect predictive factors as well as the study of affected pathways which may become selective therapeutic targets.

Tumours and tumour-like lesions of the spinal canal and spine. A review of 185 consecutive cases with more detailed close-up on some chosen pathologies

OBJECTIVES

Spinal canal tumours constitute a minor part of CNS invading neoplasm. However, due to their damaging influence on the spinal cord and the spinal roots, they cause serious clinical problems and can lead to severe disability. The aim of this study is to review material collected on tumours of the spine and the spinal canal at the Department of Neuropathology over the past ten years.

MATERIAL AND METHODS

One hundred and eighty five histopathological examinations of spinal tumours were evaluated between August 1997 and August 2007. The group of patients included 94 females and 91 males between the age of 18 and 79 years with a mean age of 53.

RESULTS

Apart from typical intraspinal tumours (i.e. astrocytomas and ependymomas), and extraspinal tumours, (i.e. meningiomas, schwannomas, neurofibromas), rare neoplastic and non-neoplastic tumour-like changes occur in the same localizations. These rare conditions include: capillary haemangioma, paraganglioma of filum terminale, meningeal gliomatosis, different variants of cysts such as the dermoid cyst, synovial cyst and aneurysmatic bone cyst, neoplastic and non-neoplastic bone tumours like the giant cell tumour, chordomas, and intramedullary metastatic carcinomas.

CONCLUSIONS

This paper presents and discusses spinal lesions from collected data with special attention paid to the rare conditions, which are reviewed in more detail.

[Surgical treatment for cervical dumbbell tumors]

OBJECTIVE

To investigate the surgical treatment for cervical dumbbell tumors.

METHODS

Clinical manifestation, surgical type and stage, and surgical method of 36 consecutive patients with cervical dumbbell tumor were retrospectively studied.

RESULTS

The tumors in 35 patients were completely resected once, and the other one patient underwent subtotal resection. Signs and symptoms of all patients were recovered to different degrees, without significant complications and tumor recurrence.

CONCLUSION

According to the type and stage of dumbbell tumors, we could adopt surgical methods through posterior or posterior combined with anterior approach, together with instruments and fusion, which could completely resect tumors and prevent complications.

Influence of the type of neoplasm and treatment on the survival of patients with malignant spinal tumours

INTRODUCTION

The skeletal system is the third most frequent (after lungs and liver) seat of metastases, and metastatic tumours are the most common type of bone malignancies. The aim of the study was to evaluate the influence of the type of neoplasm and method of treatment on the survival of patients with malignant spinal tumours.

MATERIALS AND METHODS

A retrospective analysis of 452 patients operated on between 2000 and 2004 in the Orthopaedic Surgery Hospital in Piekary Slaskie revealed a group of 203 patients whose histopathologic examination confirmed the presence of neoplastic foci in the spine. Data concerning the type of surgery and tumour location in 139 patients with the most frequent malignant spinal tumors were analyzed. The other information concerning subsequent treatment was analyzed in the Maria Skłodowska-Curie Oncology Centre and Institute in Gliwice. Patient deaths were verified in the Regional Administrative Office in Katowice.

RESULTS

The most common types of neoplasms producing spinal metastases (in patients who underwent surgery) were: breast cancer, prostatic adenocarcinoma and kidney cancer. Multiple myeloma was the most frequent diagnosis among primary bone neoplasms. The survival of patients with multiple myeloma was statistically longer than the survival of patients with renal, breast and prostatic cancer metastases. It appears that, in the absence of contraindications, the best treatment for patients with spinal metastases is locally radical surgery combined with radiation therapy (a single teleradiotherapy session of 8 Gy). This treatment resulted in a statistically significant prolongation of life of the patients.

CONCLUSIONS

The length of survival of patients with malignant spinal metastases is influenced by the type of neoplasm and locally radical surgery combined with palliative radiation therapy.

Surgery for primary vertebral tumors: en bloc versus intralesional resection

The decision to select en bloc resection or intralesional resection needs to be tailored to each individual patient and circumstance. Though complete resection with long-term progression-free survival is the goal, it is not always feasible, nor advisable, depending on what the patient's expectations are and what the risk of complications may be. However, in cases with favorable circumstances and consensus agreement between physicians, surgeons, and patients, aggressive en bloc removal of spinal tumors can be extremely valuable and may offer the only chance at cure for otherwise devastating malignancies.

Mature neuroblastic tumors with spinal cord compression: report of five pediatric cases

BACKGROUND

Neuroblastic tumors cause spinal cord compression when they arise primarily in the spinal canal or invade it through the radicular foramen. Whereas neuroblastomas (NB) are relatively common and are generally treated with chemotherapy, mature neuroblastic tumors (MNT), which include intermixed ganglioneuroblastomas (iGNB) and ganglioneuromas (GN), are less common and the role of surgery is more prominent. Because MNT are rare and have been separated only recently from NB, their clinical and radiological features as well as the role of surgery are poorly defined.

MATERIALS AND METHODS

In order to increase our knowledge on MNT, we reviewed our database for cases operated for spinal cord compression in our department since the introduction of magnetic resonance imaging (MRI). We treated four cases of NB and one case of iGNB presenting primarily with spinal cord compression.

REPORT OF CASES

MNT represented 10% of spinal tumors and 1.6% of all tumors of the nervous system in our pediatric neurosurgical practice. The neurological and oncological outcomes were generally favorable after surgical resection, followed by orthotic treatment. In one case with neurofibromatosis type 1, the tumor was inoperable and the child died of tumor progression several years later.

CONCLUSION

GN, and some iGNB, are chemo-insensitive and can only be cured by surgical removal. Surgery is an emergency in case of rapidly progressing paraplegia and can be challenging because the tumor is often hard and hemorrhagic. In case of subtotal removal, tumor remnants can stay stable without oncological treatment.

[Quality of life in patients with metastatic spinal tumors]

The authors investigated the postoperative quality of life in 89 patients with metastatic spinal tumors. As the results of our study, it was found that spinal surgery could maintain or improve the quality of life, and then most of patients with poor quality of life had multiple spine/bone metastasis or brain/spinal cord metastasis.

Use of magnetic resonance imaging in differentiating compartmental location of spinal tumors

Magnetic resonance imaging (MRI) is the best imaging modality for evaluating most spinal tumors. In this review, we describe the MRI appearance of extradural, intradural-extramedullary, and intradural-intramedullary tumors as well as the image interpretation techniques that permit identification of the compartment in which a lesion is located. In addition, we review the literature and our experience in using an anatomic classification system to narrow the differential diagnosis for patients with spine tumors. This method permits successful identification of a narrow differential diagnosis, which can be used to guide additional evaluation and treatment.

Reconstruction after total sacrectomy: early experience with a new surgical technique

Nine patients had sacrectomy with ilio-lumbar arthrodesis for treatment of sacral malignancies at our institution between 2000 and 2004. Five patients had total sacrectomy, three had a sagittal hemisacrectomy, and one had an extended internal hemipelvectomy Type I-S. The average patient age was 39 years. Tumors were Stage IIB in seven patients and Stage IB in two patients. A combined anteroposterior approach was used and a wide surgical margin was attained in all seven patients. A new form of reconstruction using structural fibular grafts and pedicle screw-rod instrumentation was used to create a triangular construct along the anatomic force transmission vectors from the femoral heads to the lumbar spine. The average followup was 18 months. At latest followup, seven patients were alive with no evidence of disease, and two had died from disease. One patient suffered postoperative infection. Independent ambulation was noted in seven patients at last followup. Eight patients had stable reconstructions at latest followup (one patient, who died in December 2004, had a stable reconstruction and was walking with braces and a walker before her death). One patient had instrumentation failure twice and had additional revision instrumentation and bone grafting procedures. She eventually obtained a solid lumbopelvic fusion and walks with Canadian crutches and ankle-foot orthoses. The technique of reconstruction reported here offers promise in dealing with the challenges of reestablishing spinopelvic stability in this difficult anatomic location.

LEVEL OF EVIDENCE

Therapeutic study, Level IV-1 (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Time to diagnosis of intraspinal tumors

The aim of this study was to assess the time to diagnosis in patients with intraspinal tumors and to assess factors contributing to a long delay in some patients. Patients who were admitted at our hospital over a 15-year period (1986-2000) with an intraspinal (either intradural or extradural) tumor were included. Records of patients were studied for variables such as sex, age, diagnosis, date of diagnosis, initial symptoms, symptoms at diagnosis, level of tumor, original diagnosis and diagnostic technique [CT-myelography, CT-caudography or magnetic resonance imaging (MRI)]. The median time to diagnosis of 108 patients with an intraspinal tumor was 12.3 months (range: 4 days-14.4 years). Most common initial symptoms were back and/or neck pain, pain radiating to one extremity and walking disturbances. There was no distinctive clinical pattern between intramedullary and extramedullary tumors regarding initial symptoms. At the time of diagnosis, patients presented with moderate to severe neurological deficits: weakness in one extremity in 26%, sphincter disturbance (20%) and paraparesis (12%). Improved imaging of the spinal cord by MRI did not result in earlier detection of the intraspinal tumor. The time to diagnosis is explained by non-specific and slowly progressing signs and symptoms. A high rate of clinical suspicion should be present to diagnose an intraspinal tumor at an early stage.

International Classification of Childhood Cancer, third edition

BACKGROUND

The third edition of the International Classification of Diseases for Oncology (ICD-O-3), which was published in 2000, introduced major changes in coding and classification of neoplasms, notably for leukemias and lymphomas, which are important groups of cancer types that occur in childhood. This necessitated a third revision of the 1996 International Classification of Childhood Cancer (ICCC-3).

METHODS

The tumor categories for the ICCC-3 were designed to respect several principles: agreement with current international standards, integration of the entities defined by newly developed diagnostic techniques, continuity with previous childhood classifications, and exhaustiveness.

RESULTS

The ICCC-3 classifies tumors coded according to the ICD-O-3 into 12 main groups, which are split further into 47 subgroups. These 2 levels of the ICCC-3 allow standardized comparisons of the broad categories of childhood neoplasms in continuity with the previous classifications. The 16 most heterogeneous subgroups are broken down further into 2-11 divisions to allow study of important entities or homogeneous collections of tumors characterized at the cytogenetic or molecular level. Some divisions may be combined across the higher-level categories, such as the B-cell neoplasms within leukemias and lymphomas.

CONCLUSIONS

The ICCC-3 respects currently existing international standards and was designed for use in international, population-based, epidemiological studies and cancer registries. The use of an international classification system is especially important in the field of pediatric oncology, in which the low frequency of cases requires rigorous procedures to ensure data comparability.

Anatomic classification system for surgical management of paraspinal tumors

HYPOTHESIS

An anatomic classification system for paraspinal tumors that identifies complexity of regional anatomy, morbidity in complete or partial resection of anatomic structures, and potential complications may assist surgeons in preoperative planning.

DESIGN

Application of a 6-level anatomic classification system for paraspinal tumors by retrospective medical record analysis. The classification system is defined by the following divisions of the vertebral column: I (C3-T3), II (T3-T10), III (T10-L2), IV (L1-L5, anterior to spine), V (L2-L5, lateral to spine), and VI (S1-S5).

PATIENTS

All patients seen by us who underwent paraspinal tumor resection between 1997 and 2002.

SETTING

Tertiary referral facility.

MAIN OUTCOME MEASURES

Level-specific preoperative and surgical procedures and expected and unexpected vascular and neurologic morbidity caused by surgical intervention.

RESULTS

Twenty-six patients met the inclusion criteria, and each of the levels (I through VI) of the classification system was represented by at least 2 patients. Expected morbidity that occurred because of surgical intervention included laryngeal paralysis in 1 patient with a level I tumor, femoral nerve palsy in 1 patient with a level V tumor, and neurogenic bladder and rectal dysfunction in 2 patients with level VI tumors. No unexpected neurologic deficit developed in any patient. Unanticipated intestinal ischemia and infarction occurred in 1 patient, who died after undergoing level IV surgery. Follow-up period ranged from 3 months to more than 5 years.

CONCLUSION

Application of this 6-level anatomic classification system based on paraspinal tumor location may allow surgeons to anticipate specific surgical problems and to evaluate risks of resection and potential complications on the basis of regional anatomy.

Primary Vertebral Osteosarcoma: Imaging Findings

PURPOSE

To evaluate patient age and sex and location and imaging appearances of primary vertebral osteosarcoma (PVOS) compared with histologic subtypes.

MATERIALS AND METHODS

Retrospective review (1915-2001) of imaging findings in patients with histologically proved primary osteosarcoma of vertebral column was performed. Two radiologists in consensus reviewed findings for location, origin site, matrix pattern, and spinal canal invasion and compared them with histologic subtypes. Radiation-induced, Paget, metastatic, and multifocal osteosarcoma were excluded.

RESULTS

Of 4,887 osteosarcoma cases, 198 (4%) were PVOS arising from vertebral column. There were 103 female and 95 male patients (age range, 8-80 years; median age, 34.5 years). Involvement included cervical (27 patients), thoracic (66 patients), lumbar (64 patients), and sacral (41 patients) spine. Adequate imaging findings were available in 69 patients, and involvement of two levels was seen in 12 (17%). In nonsacral spine, most tumors (44 cases) arose from posterior elements, with partial involvement of vertebral body. Lesions confined to vertebral body were less frequent (12 cases). Sacral tumors involved body and sacral ala. The most common histologic subtypes were osteoblastic (47 patients), chondroblastic (12 patients), telangiectatic (four patients), fibroblastic (four patients), small cell (one patient), and epithelioid (one patient). The majority (55 cases) demonstrated osteoid matrix mineralization; 17 showed marked mineralization. Five cases with marked mineralization were confined to vertebral body, with "ivory vertebra" appearance. Purely lytic pattern was seen in 14 (20%) cases. Lytic pattern was seen in four (100%) telangiectatic, three (75%) fibroblastic, three (25%) chondroblastic, three (6%) conventional osteoblastic, and one (100%) small-cell subtypes. Invasion of spinal canal was common (84% of cases). Appearance simulating osteoblastoma without soft-tissue mass was present (seven cases). Pathologic compression fractures were identified (seven patients).

CONCLUSION

This study provides age and sex distribution and location and imaging features in a large series of PVOS.

Surgical strategy for cervical dumbbell tumors based on a three-dimensional classification

STUDY DESIGN

Forty-two patients with cervical dumbbell tumors were analyzed retrospectively using a new three-dimensional classification.

OBJECTIVES

To establish optimal surgical strategies, we considered shapes and three-dimensional locations of cervical dumbbell tumors based on diagnostic images and intraoperative findings.

SUMMARY OF BACKGROUND DATA

Eden's classification for dumbbell tumors of the spine, long considered a "gold standard," no longer is sufficient to determine surgical strategy in view of recent advances in computed tomography and magnetic resonance imaging.

METHODS

Forty-two cervical dumbbell tumors were characterized according to transverse-section images (Toyama classification; nine types) and craniocaudal extent of intervertebral and transverse foraminal involvement (IF and TF staging; three stages each).

RESULTS

Type IIIa tumors, involving dura plus an intervertebral foramen, accounted for 50% of cases. A posterior approach was used in 35 patients; 7 others underwent a combined anterior and posterior approach. A posterior approach was used for all type IIa and IIIa tumors, and for some type IIIb (upper cervical), IV, and VI tumors; a combined posterior and anterior approach was used for type IIb and the remainder of type IV and VI. Reconstruction was performed using spinal instrumentation in 4 patients (9.5%). Resection was subtotal in 6 patients (14.3%) and total in 36 (85.7%).

CONCLUSIONS

Systematic, imaging-based three-dimensional characterization of shape and location of cervical dumbbell tumors is essential for planning optimal surgery. The classification used here fulfills this need.

[Spinal tumors: clinical aspects, classification and surgical treatment]

Spinal tumors are classified in intradural and extradural tumors. Most extradural spinal tumors are metastasis. The other spinal tumors are rare and mostly benign. Only about 5% of tumors of the nervous system are spinal tumors. Their symptomatology is often insidious and the diagnosis can be difficult. Magnetic resonance imaging has revolutionized their diagnosis. The lesions within the spinal cord can now be directly visualized. The treatment of these tumors mostly require surgery. It has been proven that surgical results are better if these tumors are operated as soon as neurological symptoms have appeared. In our series of 39 operated intradural tumors we noted a functional improvement in 46.5% of the cases, a stabilisation in 43.5% and a deterioration in 10%.

Metastatic disease of the spine: evaluation and treatment

Treatment of patients with metastatic disease of the spine continues to be a challenging problem. Advances in imaging studies and surgical techniques have improved patient outcomes with operative intervention. However, the lack of a validated set of criteria to determine spinal instability makes patient selection for surgical intervention difficult. Multiple classification systems that assist surgeons in determining appropriate operative candidates have been proposed. We will review current information on the evaluation and treatment of metastatic disease of the spine and discuss classification systems that assist in determining appropriate operative candidates.

Myopericytoma of the thoracic spine: a case report

STUDY DESIGN

A case of myopericytoma of the thoracic spine is reported.

OBJECTIVE

To report a recently described and extremely rare soft tissue neoplasm in the previously unreported location of the thoracic spine.

SUMMARY OF BACKGROUND DATA

Myopericytoma is a recently described soft tissue neoplasm with perivascular myoid differentiation. All cases have been reported in the subcutaneous and superficial soft tissues of the extremities. This represents the first reported case of this unusual lesion in the spine.

METHODS

A patient with a 3-month history of progressive weakness of the arms and legs was found to have a lytic lesion of T3. The lesion was surgically treated by curettage followed by a course of radiation. Presenting symptoms, imaging studies, histologic findings, and related literature are reviewed in this study.

RESULTS

Histologic evaluation of sections of the surgically removed lesion revealed a concentric, periluminal proliferation of cells with prominent positive smooth muscle actin immunoreactivity. These findings are consistent with the diagnosis of a myopericytoma, a lesion not previously reported in the spine.

CONCLUSIONS

This study shows the presence of a lesion in the thoracic spine only previously described in the soft tissue of the extremities. The diagnosis of myopericytoma should be included, along with hemangiopericytoma, in the differential diagnosis of lytic lesions of the spine.

[Surgical treatment of the vertebral column tumors compressing nervous structures]

The results of treatment of 136 patients with primary and metastatic tumors, affecting the vertebra and compressing the spinal cord or its roots were analyzed. The kind and adequacy of access, method of excision of the vertebral column tumor, volume of the tumoral resection, type of used system of the vertebral column stabilization were evaluated. Histological peculiarities of the vertebral column tumors were studied and classified.

Multiple myeloma: surgery of the spine: retrospective analysis of 27 patients

STUDY DESIGN

The authors report on the clinical course of 27 consecutive patients surgically treated for solitary or multiple myeloma of the spine.

OBJECTIVES

To evaluate the complications, neurologic function, life quality, and survival after decompression of the spinal cord and stabilization of the spinal column in cases of conventionally untreatable pain, neurologic impairment, or spinal instability.

SUMMARY OF BACKGROUND DATA

The clinical outcome in patients surgically treated for multiple myeloma of the spine has not been intensively studied. Because patients with myeloma often live longer than patients with bone metastases from other malignancies, it is important that these patients be examined and treated with methods specific to their needs and not only with those typically used for patients with metastatic disease.

METHODS

The 27 patients had undergone the following surgical procedures: two dorsal decompressions, seven dorsal decompressions and stabilizations, 15 ventral decompressions and stabilizations, and three ventral and dorsal decompressions and stabilizations. Quality of life was measured by the Karnofsky Index, neurologic impairment according to Frankel, and survival by the Kaplan-Meier method.

RESULTS

Life quality improved from 48% before surgery to 59% 1 month after surgery and 73% in 24 survivors after the first year. Comparison of their presurgical scores with the scores obtained 1 month after surgery revealed that 18 patients had improved, five patients stayed the same, and four patients declined. After 1 year the scores of all 24 surviving patients had improved from their presurgical levels. In the 21 patients with unimpaired preoperative neurologic function, one patient developed a paraparesis as a complication of surgery, while 20 remained unimpaired until death or 1 year after treatment. All six patients with neurologic deficits improved, two of them to normal function. Pain relief was evident in 26 cases. The mean length of postoperative survival was 49.7 months. Local tumor recurrence occurred in three of 27 patients (11.1%).

CONCLUSION

The surgical treatment of myeloma of the spine seems to be an effective method of treatment with respect to neurologic function and life quality in selected cases.

Evaluation and treatment of spinal metastases: an overview

Metastases to the spine are a common and somber manifestation of systemic neoplasia. The incidence of spinal metastases continues to increase, likely a result of increasing survival times for patients with cancer. Historically, surgery for spinal metastases has consisted of simple decompressive laminectomy. Results obtained in retrospective case series, however, have shown that this treatment provides little benefit to the patient. With the advent of better patient-related selection practices, in conjunction with new surgical techniques and improved postoperative care, the ability of surgical therapy to play an important and beneficial role in the multidisciplinary care of cancer patients with spinal disease has improved significantly. Controversy remains, however, with respect to the relative merits of surgery, radiotherapy, chemotherapy, or a combination of these treatments.

In this topic review, the literature on spinal column and spinal cord metastases is collated to provide a description of the presentation, investigations, indications for surgical therapy, and the role of adjuvant cancer therapies for patients with spinal metastases. In addition, the authors discuss the different surgical strategies available in the armamentarium of the neurosurgeon treating patients with spinal metastasis.

Cancer and the nervous system

Brain tumours should be considered when patients present with headache with diurnal variation, seizures, or progressive neurological symptoms. Spinal cord compression by tumour is a medical emergency. Prognosis for patients with glioma is better in those with tumours of low grade, and in patients younger than 50 years and with higher functional levels. Surgery, radiotherapy and chemotherapy can improve survival for patients. Anticancer therapies can have neurotoxic side effects.

Semeiotics of bone tumors in children

In recent years, the study of bone disorders has changed thanks to the progressive development of imaging techniques. In our opinion, however, different from what happens in the study of pathologic conditions in other organs and systems, conventional radiology remains the diagnostic cornerstone for bone disorders and especially bone tumors. In any case, plain radiography must always be performed first. The radiologic approach to primary bone tumors includes a series of steps to collect the necessary information to suggest, with the following contribution of radiography, the most likely diagnosis. The approach is basically statistical and many parameters should be considered. As far as bone tumors in children are concerned, the basic role of the statistical variable 'patient age' is apparent and this information should be considered even before any others. Despite the difficulties in assessing the frequency of bone tumors we tried to read homogeneously some of the statistical data reported in literature. Tumor incidence in a given age class is a very important diagnostic tool. Lesion location is the second step in the radiologic work-up: the involved bone and bone segment should be assessed and correlated with the preferential site of a specific tumor. Regarding the bone tumors detected in the first 5 years of life, an interesting question is whether a vertebra plana is due to a benign or a malignant lesion. The lytic lesion will be well defined by CT and MRI will be very useful in depicting bone marrow and surrounding soft tissue involvement. However, many processes have a similar imaging pattern. We believe that before biopsy the frequent, marked infiltration of surrounding soft tissues in vertebra plana should suggest a diagnosis of malignant tumor rather than of tumor-like lesion.

Reconstruction techniques in the treatment of vertebral neoplasms

The authors present a new system for the topographical description of vertebral neoplasms. The general criteria of reconstruction after curettage or vertebral resection are evaluated. The literature is reviewed in terms of the use of prostheses, bone grafts, cement and stabilization systems in the treatment of tumors of the spine. Indications for the different methods are discussed.

Vertebral metastases: a critical appreciation of the preoperative prognostic tokuhashi score in a series of 71 cases

STUDY DESIGN

The utility of the Tokuhashi score was assessed in a retrospective study in 71 patients with vertebral metastases.

OBJECTIVES

To study the importance of the site of the primary tumor as a parameter in the preoperative prognostic Tokuhashi score.

SUMMARY OF BACKGROUND DATA

A preoperative score composed of six parameters, each rated from zero to two, has been proposed by Tokuhashi for the prognostic assessment of patients with metastases to the spine.

METHODS

Seventy-one patients with vertebral metastases were studied. There were 34 cases of thyroid cancer metastases, 28 cases of renal cancer metastases, and nine cases of metastases of unknown origin. In each patient, a local and a systemic tumor search were performed. Patients were divided into groups based on the primary site of the tumor, and each group was analyzed separately.

RESULTS

In cases of vertebral metastases of thyroid cancers, surgery to excise single metastases was found to provide good results, as was palliative surgery of multiple metastases. Vertebral metastases of renal tumors were rarely single, and the results of palliative surgery were less satisfactory. Vertebral metastases of unknown primary tumors had a poor outcome, regardless of whether surgery was excisional or palliative. The median survival period in patients with metastases of unknown primary tumors was significantly shorter than that in patients with renal or thyroid cancer metastases.

CONCLUSION

The Tokuhashi preoperative score is successful as a prognostic tool. However, it attributes the same one-point rating to metastases of renal cancer and to those of unknown primary tumors. In the case of metastases of unknown primary tumors, this rating is too high and should be reduced to 0.

Chordoma: a case report

BACKGROUND

Chordomas are tumors of notochordal origin that account for approximately 1%-4% of all primary malignant bone tumors. The majority of patients with chordomas have a poor surgical prognosis due to extent of disease at diagnosis. These lesions have been previously classified based solely on their location.

METHODS

We describe here a case report of a posterior epidural C5-T1 chordoma that was discovered in a young patient who presented with weakness and paresthesia in all four extremities. This lesion was notable for its extraosseous and extradural characteristics.

RESULTS

C5-T1 laminectomy with gross total resection of the mass led to complete resolution of all symptoms. There has been no evidence of tumor recurrence to date.

CONCLUSIONS

We propose here a new classification system for chordomas that emphasizes the difference in resectability of these lesions depending on the space they occupy and the presence or absence of an osseous connection.

Extracranial non-testicular teratoma in childhood and adolescence: introduction of a risk score for stratification of therapy

PATIENTS AND METHODS

According to previous literature incomplete tumor resection, coccygeal or ovarian primary site and immaturity are known risk factors for relapse in teratoma. To establish a risk score points are allocated for resection, primary site and histology in the following manner and added: incomplete resection 4 points, primary site coccyx 3 points, ovary 2 points, other site 1 point, histological grading 0-3 points. This score system is evaluated on 270 extracranial non-testicular teratoma cases collected between 1982 and 1995 in the MAKEI cooperative treatment protocols of the German Society of Pediatric Oncology and Hematology. Treatment was resection alone (230 patients) or resection followed by postoperative adjuvant chemotherapy (40 patients).

RESULTS

Patients treated with surgery alone: 28/230 (12%) patients relapsed, 14/230 (6%) patients showed highly malignant histology (mostly yolk sac tumor) in relapse. Mortality in case of relapse was 6/28 (21%). Patients scoring > or = 6 points (n = 45) had a relapse rate of 21/45 (47%) resulting in a 23%-mortality (5/21). Patients scoring < 6 points (n = 185) had a 4%-relapse risk (8/185) resulting in 13%-mortality (1/8) (p < 0.01). Patients treated with surgery and adjuvant chemotherapy: 7/40 patients (18%) suffered a relapse, none of them showing malignant histology. Mortality rate in case of relapse was 3/7 (43%). Patients scoring > or = 6 points initially treated with adjuvant chemotherapy (n = 18) had a relapse rate of 7/18 (39%), compared to patients scoring < 6 points (n = 22), in whom no relapses occurred (p < 0.01). There were no highly malignant relapses in the group treated with adjuvant chemotherapy. Regardless of the scored points the difference in highly malignant relapse histology comparing the group treated with surgery and adjuvant chemotherapy to the group treated with surgery was statistically significant (p = 0.02).

CONCLUSION

The risk score system marks a high risk group including 63/270 (23%) of all evaluated extracranial non-testicular teratoma cases (scoring > or = 6 points). In this group 28/35 (80%) of relapses and 8/9 (89%) of tumor deaths occurred. For this high risk group a randomized trial will be suggested to evaluate the effect of adjuvant chemotherapy on the rate of malignant relapses. It should also be investigated, if adjuvant chemotherapy will influence relapse rate and mortality.

Color Doppler aided prenatal diagnosis of a type 1 cystic sacrococcygeal teratoma simulating a meningomyelocele

Type 1 cystic sacrococcygeal teratomas, usually associated with good outcome following neonatal resection, must be differentiated at the time of prenatal diagnosis from sonographically similar meningomyeloceles, which carry a grave prognosis. We present an unusual case in which color Doppler imaging assisted correct midtrimester prenatal diagnosis of a large type 1 cystic sacrococcygeal teratoma closely simulating a meningomyelocele.

Occult spinal dysraphism--the common combination of lesions and the clinical manifestations in 50 patients

Fifty patients (26 males, 24 females) aged from birth to 51 years with occult spinal dysraphism were identified. All had Magnetic Resonance (MR) scans carried out. The MR scans were examined to determine the vertebral level of the conus and to see if one or more of the following were present; lipoma, syrinx, dermoid, diastematomyelia, and meningocele. In 43 patients the conus lay below the level of L3, 23 had a lipoma, 23 a meningocele, 20 an open central canal in the spinal cord or a syrinx, 15 a diastematomyelia and 4 a dermoid. The commonest combination of lesions was a long cord, a syrinx or an open central canal in the spinal cord and a lipoma. The diastematomyelias were always associated with a long cord and had the highest incidence of vertebral body anomalies (60%). The most frequent recorded signs were deformities of the feet, short legs, wasting of the calf muscles, weakness of the legs, back pain and bladder dysfunction. Combinations of these occurred with all of the lesions although some had none. Whilst deterioration was seen in about half of the patients, acute deterioration was uncommon and was associated most frequently with a dermoid or an expanded syrinx.

Evaluation of surgery for the tethered cord syndrome using a new grading system

A new grading system is presented to assess the degree of untethering achieved at surgery for the 'tethered cord syndrome' based on intraoperative observation at the end of the procedure. Various pathophysiological mechanisms responsible for the 'tethered cord syndrome', as well as possible factors causing retethering were considered in developing this grading system. In Grade I the cord is considered to be fully untethered and the factors potentially responsible for retethering are eliminated, in Grade II partial untethering is performed and in Grade III untethering is unsuccessful. This grading system was used to assess the results of 22 consecutive operations performed to release a tethered cord between June 1991 and February 1995. The tethering factors encountered at surgery were: spinal lipoma in 14, diastematomyelia in five, a tight filum terminale in 10 and intradural adhesions in three instances. The grade of untethering was correlated with the type of pathology encountered, postoperative results, and whether previous surgery was performed or not. Previous surgery was found not to affect the rate of subsequent successful untethering.

[Familial sacrococcygeal teratoma]

Familial sacrococcygeal teratomas are very rare. Up to now, only 8 kindreds (31 patients, including 1 Japanese kindreds) have been reported. All cases are Altman type IV variety. The tumor complex consists of a presacral teratoma and sacrococcygeal bony anomalies. The most common symptoms are constipation and anorectal stenosis. Two patients died. One died of meningitis following removal of a large benign tumor because of communication with a spinal arachinoid space. The other, with a large benign tumor, died as a result of malignant change, 10 years later after the first operation. The incidence of malignant change of familiar sacrococcygeal teratoma is rare in comparison with that of non-familiar sacrococcygeal teratomas.

Tethered cord syndrome: the low-lying and normally positioned conus

We have previously proposed the existence of the tethered cord syndrome in the presence of a conus medullaris in the normal position. Our 12-year series of 73 patients with the tethered cord syndrome included 13 patients in whom the spinal cord terminated at or above the L1-L2 disc space. We compare the characteristics of these 13 with those of the 60 patients whose spinal cord terminated below the L1-L2 disc space. The parameters for comparison included neurological status at presentation and follow-up, the presence of cutaneous stigmata of occult spinal dysraphism, vertebral anomalies, and others. The frequency of occurrence of each parameter in the normally positioned group was essentially the same as its occurrence in the low-lying group.

Metastatic vertebral disease in children

We retrospectively reviewed 19 children with osseous vertebral metastases. The average age was 10.9 years at diagnosis of the primary tumor and 11.2 years at diagnosis of metastasis. The location of the multiple metastases was cervical (three), thoracic (14), and lumbar (10). Treatment consisted of chemotherapy (19), radiation therapy (12), and operation (seven). Ten children died at an average of 13 months after diagnosis of the primary tumor; nine are alive at an average of 72 months after diagnosis. All four children treated with chemotherapy, spinal radiation, and laminectomy, and who survived > 2 months, developed deformity. In this particular situation, we encourage consideration of spinal stabilization when it is appropriately coordinated with radiation and chemotherapy.

Reflections on notochordal differentiation arising from a study of chordomas

This study of thirteen cases of chordoma serves to emphasize the occurrence of three different histological patterns; classical, seven; chondroid, three; and intermediate or mesenchymal, three. The study also suggests that more adequate sampling of these tumours detects the chondroid variant more readily. These varying patterns of differentiation in tumours of notochordal origin suggest that the parent tissue may have the potential to develop along similar lines in the embryo. Thus mesenchymal and cartilaginous tissue formed from notochordal cells could contribute to the formation of the nucleus pulposus and inner portion of the intervertebral disc cartilages. This concept contrasts with the previously held view that the notochord atrophies at an early stage in embryonic development.

[Epidemiology and pathology of spinal tumors]

Spinal tumors are not very frequent; they represent 8-15% of the tumors of the central nervous system. In adulthood, more than a half of them are intradural extramedullary tumors; the most frequent oncotype is neurinoma, followed by meningioma. The frequency of astrocytomas of the spine is comparable with that of the brain, taking into account the different weights of the two organs; on the contrary, the frequency of ependymomas is higher than in the brain. In childhood, spinal tumors are quite infrequent . Some oncotypes are typical of infancy: neuroblastoma, teratoma, sarcoma. The pathological peculiarities of some oncotypes due to the spinal location are discussed.

[Diagnostic picture of spinal tumors]

A correct classification both primary and secondary of the spinal tumour is given dealing with a present argument. The clinical aspect and The radiology of the different kinds of tumour are specified. Moreover they are classified according to their anatomo-pathological aspect. A complete analysis of the argument is the result of this work.

Metastatic tumors involving the cervical vertebrae: surgical palliation

Pain, weakness, or paralysis from involvement of the spinal cord and nerve roots secondary to invasion of the vertebrae by a malignant tumor often can be avoided or alleviated by stabilization of the spine. Twelve patients with neoplastic infiltration of the cervical vertebrae were so treated. The operation of wiring, augmentation bone-grafting, and decompression of the spinal cord was successful after conservative methods failed. Indications for operation were: (1) unremitting pain in the neck, not relieved by bracing or radiation therapy; (2) a major degree of vertebral destruction with loss, or impending loss, of support for the head; (3) collapse of a vertebral body; or (4) neural deficit from local tumor invasion. A classification of our twelve patients into three groups helped to delineate the surgical procedure needed. The value of obtaining spinal stability and a solid fusion above and below the tumor was evident in eleven patients. For almost all of their survival time, they were comfortable. Surgical treatment may not appreciably extend the lenght of a patient's survival, but it generally improves the patient's quality of life.