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Gao X, Wu Z, Wang T, Cao J, Bai G, Xin B, Cao S, Jia Q, Liu T, Xiao J. A Discussion on the Criteria for Surgical Decision-Making in Elderly Patients With Metastatic Spinal Cord Compression. Global Spine J 2023; 13:45-52. [PMID: 33525916 PMCID: PMC9837498 DOI: 10.1177/2192568221991107] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
STUDY DESIGN Retrospective study. OBJECTIVES Although the role of surgery in the management of metastatic spinal cord compression (MSCC) has been well established, elderly patients may still be denied surgery because of higher risk of complications and shorter life expectancy. The purpose of this study was to determine whether elderly patients with MSCC could benefit from surgery and discuss the criteria for surgical decision-making in such patients. METHODS Enrolled in this study were 55 consecutive patients aged 75 years or older who were surgically treated for MSCC in our center. Prognostic factors predicting overall survival (OS) were explored by the Kaplan-Meier method and Cox regression model. The quality of life (QoL) of the patients was evaluated by the SOSGOQ and compared using Student's t test. Risk factors for postoperative complications were identified by Chi-square test and multiple logistic regression analysis. RESULTS Surgical treatment for MSCC substantially improved the neurological function in 55.8% patients and QoL in 88.5% patients with acceptable rates of postoperative complications (16.4%), reoperation (9.1%), and 30-day mortality (1.8%). Postoperative ECOG-PS of 1-2, total en-bloc spondylectomy (TES), and postoperative chemotherapy were favorable prognostic factors for OS, while a high Charlson Comorbidity Index (CCI) and a long operation time were risk factors for postoperative complications. CONCLUSIONS Surgery should be encouraged for elderly patients with MSCC 1) who are compromised by the current or potential neurological dysfunction; 2) with radioresistant tumors; 3) with spinal instability; and 4) with no comorbidity, ECOG-PS of 0-2, and systemic treatment adherence. In addition, surgery should be performed by a skilled and experienced surgical team.
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Affiliation(s)
- Xin Gao
- Orthopaedic Oncology Center, Department
of Orthopedics, Changzheng Hospital, Navy Medical University, Shanghai, China
| | - Zheyu Wu
- Orthopaedic Oncology Center, Department
of Orthopedics, Changzheng Hospital, Navy Medical University, Shanghai, China,Department of Orthopedics, Zhongnan
Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Tao Wang
- Orthopaedic Oncology Center, Department
of Orthopedics, Changzheng Hospital, Navy Medical University, Shanghai, China,Department of Orthopedics, Second
Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Jiashi Cao
- Orthopaedic Oncology Center, Department
of Orthopedics, Changzheng Hospital, Navy Medical University, Shanghai, China
| | - Guangjian Bai
- Orthopaedic Oncology Center, Department
of Orthopedics, Changzheng Hospital, Navy Medical University, Shanghai, China
| | - Baoquan Xin
- Orthopaedic Oncology Center, Department
of Orthopedics, Changzheng Hospital, Navy Medical University, Shanghai, China
| | - Shuang Cao
- Orthopaedic Oncology Center, Department
of Orthopedics, Changzheng Hospital, Navy Medical University, Shanghai, China
| | - Qi Jia
- Orthopaedic Oncology Center, Department
of Orthopedics, Changzheng Hospital, Navy Medical University, Shanghai, China,Qi Jia, Tielong Liu, and Jianru Xiao,
Orthopaedic Oncology Center, Department of Orthopaedics, Changzheng Hospital,
No. 415 Fengyang Road, Huangpu District, Shanghai, China. Emails:
; ;
| | - Tielong Liu
- Orthopaedic Oncology Center, Department
of Orthopedics, Changzheng Hospital, Navy Medical University, Shanghai, China,Qi Jia, Tielong Liu, and Jianru Xiao,
Orthopaedic Oncology Center, Department of Orthopaedics, Changzheng Hospital,
No. 415 Fengyang Road, Huangpu District, Shanghai, China. Emails:
; ;
| | - Jianru Xiao
- Orthopaedic Oncology Center, Department
of Orthopedics, Changzheng Hospital, Navy Medical University, Shanghai, China,Qi Jia, Tielong Liu, and Jianru Xiao,
Orthopaedic Oncology Center, Department of Orthopaedics, Changzheng Hospital,
No. 415 Fengyang Road, Huangpu District, Shanghai, China. Emails:
; ;
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Nakajima H, Watanabe S, Honjoh K, Izubuchi Y, Watanabe Y, Tanaka T, Matsumine A. Prognosis after Palliative Surgery for Patients with Spinal Metastasis: Comparison of Predicted and Actual Survival. Cancers (Basel) 2022; 14:cancers14163868. [PMID: 36010862 PMCID: PMC9405944 DOI: 10.3390/cancers14163868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/28/2022] [Accepted: 08/08/2022] [Indexed: 11/18/2022] Open
Abstract
Simple Summary Increased options for cancer treatment have made the prediction of prognosis an important factor in therapeutic decision making. The aim of this study was to assess the clinical significance of prognosis–scoring systems and to identify predictors for 6–month mortality after palliative surgery. The median actual survival period was longer than the predicted life expectancy based on the revised Tokuhashi score and new Katagiri score. However, 21.3% of patients died of cancers within 6 months after palliative surgery. A statistical analysis showed that a higher CRP/albumin ratio (odds ratio: 0.39; cut–off 0.409) and absence of postoperative adjuvant therapy (odds ratio: 7.15) were independent risk factors for poor survival. Our findings suggest the need for careful consideration to determine if palliative surgery is the best option for a patient with these negative prognostic factors, regardless of life expectancy predicted based on a prognosis score. Abstract Prediction of prognosis is a key factor in therapeutic decision making due to recent the development of therapeutic options for spinal metastases. The aim of the study was to examine predictive scoring systems and identify prognostic factors for 6–month mortality after palliative surgery. The participants were 75 patients with spinal metastases who underwent palliative surgery and had a minimum follow–up period of 1 year. Associations of actual survival with categories based on the revised Tokuhashi score and new Katagiri score were evaluated. Univariate and multivariate analyses were performed to identify prognostic factors for 6–month mortality after palliative surgery. The median actual survival period was longer than those predicted using the scoring systems. However, 21.3% of patients died of cancers within 6 months after surgery. A higher CRP/albumin ratio (odds ratio: 0.39; cut–off 0.409) and absence of postoperative adjuvant therapy (odds ratio: 7.15) were independent risk factors for 6–month mortality. There was no association of mortality with primary site, severity of sarcopenia, or other biomarkers. These results suggest that careful consideration is needed to determine whether palliative surgery is the best option for patients with a high preoperative CRP/albumin ratio and/or absence of postoperative adjuvant therapy, regardless of predictions made from scoring systems.
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Current Advances in Spinal Diseases of the Elderly: Introduction to the Special Issue. J Clin Med 2021; 10:jcm10153298. [PMID: 34362083 PMCID: PMC8347409 DOI: 10.3390/jcm10153298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 07/23/2021] [Indexed: 11/29/2022] Open
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Lun DX, Chen NW, Feng JT, Yang XG, Xu ZW, Li F, Hu YC. Visceral Metastasis: A Prognostic Factor of Survival in Patients with Spinal Metastases. Orthop Surg 2020; 12:552-560. [PMID: 32227458 PMCID: PMC7189062 DOI: 10.1111/os.12657] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/11/2020] [Accepted: 02/19/2020] [Indexed: 12/12/2022] Open
Abstract
Objective To characterize the visceral metastasis as a predictive tool for the survival of patients with spinal metastases through an exploratory meta‐analysis. Methods Two investigators independently searched PubMed and Embase databases for eligible studies from 2000–2016. The effect estimates for the hazard ratio (HR) or risk ratio (RR) and 95% confidence interval (CI) were collected and pooled with a random‐ or fixed‐effect model. Results In total, 18 eligible studies were retrieved with 5468 participants from nine countries. The overall pooled effect size for HR and RR was 1.50 and 3.79, respectively, which was proved to be statistically significant. In the subgroup of prostate cancer (PCa) and non‐small cell lung cancer (NSCLC), statistical significance and marginal statistical significance was presented for the pooled HR (HR = 1.76, 95% CI 1.35–2.29) and (RR = 1.56, 95% CI 0.99–2.48), respectively. However, in the subgroup of thyroid cancer, breast cancer, and renal cancer, statistical significance was not achieved (HR = 1.17, 95% CI 0.75–1.83, Z = 0.70, P = 0.486). The results did not show any evidence of publication bias. Conclusions This study demonstrated that visceral metastasis was a significant prognostic factor in patients with spinal metastases as a whole. Interestingly, the onset of visceral metastases differentially impacted the survival in different primary tumors. Therefore, the prognostic value of visceral metastasis might be related to the type of primary tumor.
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Affiliation(s)
- Deng-Xing Lun
- Department of Spine Surgery, Weifang People's Hospital, Weifang, China
| | - Nai-Wang Chen
- Department of Spine Surgery, Weifang People's Hospital, Weifang, China
| | - Jiang-Tao Feng
- Graduate School of Tianjin Medical University, Tianjin, China
| | - Xion-Gang Yang
- Graduate School of Tianjin Medical University, Tianjin, China
| | - Zhao-Wan Xu
- Department of Spine Surgery, Weifang People's Hospital, Weifang, China
| | - Feng Li
- Department of Spine Surgery, Weifang People's Hospital, Weifang, China
| | - Yong-Cheng Hu
- Department of Bone Oncology, Tianjin Hospital, Tianjin, China
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Yang XG, Feng JT, Wang F, He X, Zhang H, Yang L, Zhang HR, Hu YC. Development and validation of a prognostic nomogram for the overall survival of patients living with spinal metastases. J Neurooncol 2019; 145:167-176. [DOI: 10.1007/s11060-019-03284-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/31/2019] [Indexed: 11/29/2022]
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Igoumenou VG, Mavrogenis AF, Angelini A, Baracco R, Benzakour A, Benzakour T, Bork M, Vazifehdan F, Nena U, Ruggieri P. Complications of spine surgery for metastasis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 30:37-56. [DOI: 10.1007/s00590-019-02541-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 08/28/2019] [Indexed: 02/07/2023]
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Yang XG, Wang F, Feng JT, Hu YC, Lun DX, Hua KC, Liu YH, Zhang H, Yang L. Recursive Partitioning Analysis (RPA) of Prognostic Factors for Overall Survival in Patients with Spinal Metastasis: A New System for Stratified Treatment. World Neurosurg 2019; 127:e124-e131. [DOI: 10.1016/j.wneu.2019.02.183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 02/18/2019] [Accepted: 02/19/2019] [Indexed: 10/27/2022]
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Yang XG, Lun DX, Hu YC, Liu YH, Wang F, Feng JT, Hua KC, Yang L, Zhang H, Xu MY, Zhang HR. Prognostic effect of factors involved in revised Tokuhashi score system for patients with spinal metastases: a systematic review and Meta-analysis. BMC Cancer 2018; 18:1248. [PMID: 30545326 PMCID: PMC6293585 DOI: 10.1186/s12885-018-5139-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 11/27/2018] [Indexed: 12/14/2022] Open
Abstract
Background Cancer patients’ survival time has obviously improved, with the development of systemic treatment techniques. However, the probability of metastases to the vertebrae has also been increased which makes some adverse effects on patients’ quality of life. The prediction of survival plays a key role in choosing therapeutic modality, and Tokuhashi Score was established as one of the most commonly used predictive systems for spinal metastases. Thus, this study was conducted to identify the prognostic effect of factors involved in revised Tokuhashi Score (RTS). Methods Two investigators independently retrieved relevant literature on platforms of PubMed, Embase and Cochrane Library. We identified eligible studies through title/abstract and full-text perusing. Data was extracted including general information of studies, participants’ characteristics, therapeutic modality, overall survival and prognostic effect of factors. Hazard ratio (HR) for each factor was synthesized if available through fixed- or random-effect models as appropriate. Results A total of 63 eligible studies with 10,411 participants were identified. Overall, cases with thyroid cancer had the highest survival rate, while the ones with non-small cell lung cancer and hepatocellular carcinoma lived for the shorted survival time. Performance status, bone metastasis, number of involved vertebrae, visceral metastasis, primary tumor and neurological status were regarded as significant predictors in 71.4, 40.0, 18.2, 63.4, 73.1 and 44.7% of the involved studies respectively. Thirty-eight articles were included in meta-analysis, and prognostic effects of five factors (apart from primary tumor) were analyzed. Factors were all proved to be significant except comparisons between KPS (Karnofsky Performance Status) 10–40 VS. 50–70 and single VS. multiple spinal metastases. Conclusion All factors of RTS were significant on prognosis predicting and should be considered when choosing therapeutic modality for spinal metastases. What’s more, we believe that more accurate prognosis may be obtained after removal of the cut-offs for KPS 10–40 VS. 50–70 and single VS. multiple involved vertebrae. Electronic supplementary material The online version of this article (10.1186/s12885-018-5139-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xiong-Gang Yang
- Department of Bone Tumor of Tianjin Hospital, Tianjin, 300211, China
| | | | - Yong-Cheng Hu
- Department of Bone Tumor of Tianjin Hospital, Tianjin, 300211, China.
| | | | - Feng Wang
- Tianjin Medical university, Tianjin, 300070, China
| | | | - Kun-Chi Hua
- Tianjin Medical university, Tianjin, 300070, China
| | - Li Yang
- Tianjin Medical university, Tianjin, 300070, China
| | - Hao Zhang
- Tianjin Medical university, Tianjin, 300070, China
| | - Ming-You Xu
- Tianjin Medical university, Tianjin, 300070, China
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Yang XG, Han Y, Wang F, Liu YH, Hu YC, Lun DX, Feng JT, Hua KC, Yang L, Zhang H, Xu MY, Zhang HR. Is Ambulatory Status a Prognostic Factor of Survival in Patients with Spinal Metastases? An Exploratory Meta-analysis. Orthop Surg 2018; 10:173-180. [PMID: 30133148 DOI: 10.1111/os.12393] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 06/04/2018] [Indexed: 01/31/2023] Open
Abstract
This study was conducted to identify the influence of ambulatory status prior to treatment on survival of patients with spinal metastases. Two investigators independently retrieved relevant electronic literature in PubMed, Embase, and Cochrane Library databases, to identify eligible studies. Effect estimates for hazard risk (HR) were extracted and synthesized through fixed-effects or random-effects models as appropriate. A total of 17 eligible studies were identified, with an accumulated number of 3962 participants. HR from 14 studies regarding comparison between ambulatory versus non-ambulatory groups were pooled using a random-effects model, and statistical significance was presented for the pooled HR (HR = 1.96; 95% confidence interval [CI], 1.65-2.34). In subgroups of mixed primary tumor and lung cancer, ambulatory status was considered to be a significant prognostic factor (P < 0.05), while in the subgroup of prostate cancer it was not (HR = 1.72; 95% CI, 0.79-3.74). HR from 4 studies related to comparison between Frankel E versus Frankel C-D were pooled using a fixed-effects model, which revealed statistical significance (HR = 1.73; 95% CI, 1.27-2.36). Ambulatory status is a significant prognostic factor in patients with spinal metastases. However, in patients with primary prostate cancer, the prognostic effect of ambulatory status has not yet been confirmed to be significant.
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Affiliation(s)
| | - Yue Han
- Department of Spine Surgery, Tianjin Hospital, Tianjin, China
| | - Feng Wang
- Graduate School, Tianjin Medical University, Tianjin, China
| | - Yong-Heng Liu
- Graduate School, Tianjin Medical University, Tianjin, China
| | - Yong-Cheng Hu
- Department of Bone Tumor, Tianjin Hospital, Tianjin, China
| | - Deng-Xing Lun
- Department of Spine Surgery, Weifang People's Hospital, Shandong, China
| | - Jiang-Tao Feng
- Graduate School, Tianjin Medical University, Tianjin, China
| | - Kun-Chi Hua
- Graduate School, Tianjin Medical University, Tianjin, China
| | - Li Yang
- Graduate School, Tianjin Medical University, Tianjin, China
| | - Hao Zhang
- Graduate School, Tianjin Medical University, Tianjin, China
| | - Ming-You Xu
- Graduate School, Tianjin Medical University, Tianjin, China
| | - Hao-Ran Zhang
- Graduate School, Tianjin Medical University, Tianjin, China
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Bakar D, Tanenbaum JE, Phan K, Alentado VJ, Steinmetz MP, Benzel EC, Mroz TE. Decompression surgery for spinal metastases: a systematic review. Neurosurg Focus 2017; 41:E2. [PMID: 27476844 DOI: 10.3171/2016.6.focus16166] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The aim of this study was to systematically review the literature on reported outcomes following decompression surgery for spinal metastases. METHODS The authors conducted MEDLINE, Scopus, and Web of Science database searches for studies reporting clinical outcomes and complications associated with decompression surgery for metastatic spinal tumors. Both retrospective and prospective studies were included. After meeting inclusion criteria, articles were categorized based on the following reported outcomes: survival, ambulation, surgical technique, neurological function, primary tumor histology, and miscellaneous outcomes. RESULTS Of the 4148 articles retrieved from databases, 36 met inclusion criteria. Of those included, 8 were prospective studies and 28 were retrospective studies. The year of publication ranged from 1992 to 2015. Study size ranged from 21 to 711 patients. Three studies found that good preoperative Karnofsky Performance Status (KPS ≥ 80%) was a significant predictor of survival. No study reported a significant effect of time-to-surgery following the onset of spinal cord compression symptoms on survival. Three studies reported improvement in neurological function following surgery. The most commonly cited complication was wound infection or dehiscence (22 studies). Eight studies reported that preoperative ambulatory or preoperative motor status was a significant predictor of postoperative ambulatory status. A wide variety of surgical techniques were reported: posterior decompression and stabilization, posterior decompression without stabilization, and posterior decompression with total or subtotal tumor resection. Although a wide range of functional scales were used to assess neurological outcomes, four studies used the American Spinal Injury Association (ASIA) Impairment Scale to assess neurological function. Four studies reported the effects of radiation therapy and local disease control for spinal metastases. Two studies reported that the type of treatment was not significantly associated with the rate of local control. The most commonly reported primary tumor types included lung cancer, prostate cancer, breast cancer, renal cancer, and gastrointestinal cancer. CONCLUSIONS This study reports a systematic review of the literature on decompression surgery for spinal metastases. The results of this study can help educate surgeons on the previously published predictors of outcomes following decompression surgery for metastatic spinal disease. However, the authors also identify significant gaps in the literature and the need for future studies investigating the optimal practice with regard to decompression surgery for spinal metastases.
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Affiliation(s)
- Dara Bakar
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Joseph E Tanenbaum
- Center for Spine Health, and ,Case Western Reserve University School of Medicine;,Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, Ohio
| | - Kevin Phan
- NeuroSpine Surgery Research Group, Prince of Wales Private Hospital, Sydney, Australia; and.,University of New South Wales, Sydney, Australia
| | - Vincent J Alentado
- Center for Spine Health, and ,Case Western Reserve University School of Medicine
| | | | - Edward C Benzel
- Center for Spine Health, and ,Departments of 2 Neurosurgery and
| | - Thomas E Mroz
- Center for Spine Health, and ,Departments of 2 Neurosurgery and.,Orthopaedic Surgery, Cleveland Clinic
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Rades D, Conde-Moreno AJ, Segedin B, Veninga T, Cacicedo J, Schild SE. A Prognostic Instrument to Estimate the Survival of Elderly Patients Irradiated for Metastatic Epidural Spinal Cord Compression From Lung Cancer. Clin Lung Cancer 2016; 17:279-84. [DOI: 10.1016/j.cllc.2015.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 10/13/2015] [Indexed: 12/17/2022]
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George R, Sundararaj JJ, Govindaraj R, Chacko AG, Tharyan P. Interventions for the treatment of metastatic extradural spinal cord compression in adults. Cochrane Database Syst Rev 2015; 2015:CD006716. [PMID: 26337716 PMCID: PMC6513178 DOI: 10.1002/14651858.cd006716.pub3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Metastatic extradural spinal cord compression (MESCC) is treated with radiotherapy, corticosteroids, and surgery, but there is uncertainty regarding their comparative effects. This is an updated version of the original Cochrane review published in theCochrane Database of Systematic Reviews (Issue 4, 2008). OBJECTIVES To determine the efficacy and safety of radiotherapy, surgery and corticosteroids in MESCC. SEARCH METHODS In March 2015, we updated previous searches (July 2008 and December 2013) of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, LILACS, CANCERLIT, clinical trials registries, conference proceedings, and references, without language restrictions. We also contacted experts for relevant published, unpublished and ongoing trials. SELECTION CRITERIA Randomised controlled trials (RCTs) of radiotherapy, surgery and corticosteroids in adults with MESCC. DATA COLLECTION AND ANALYSIS Three authors independently screened and selected trials, assessed risk of bias, and extracted data. We sought clarifications from trial authors. Where possible, we pooled relative risks with their 95% confidence intervals, using a random effects model if heterogeneity was significant. We assessed overall evidence-quality using the GRADE approach. MAIN RESULTS This update includes seven trials involving 876 (723 evaluable) adult participants (19 to 87 years) in high-income countries. Most were free of the risk of bias. Different radiotherapy doses and schedulesTwo equivalence trials in people with MESCC and a poor prognosis evaluated different radiotherapy doses and schedules. In one, a single dose (8 Gray (Gy)) of radiotherapy (RT) was as effective as short-course RT (16 Gy in two fractions over one week) in enhancing ambulation in the short term (65% versus 69%; risk ratio (RR) was 0.93, (95% confidence interval (CI) 0.82 to 1.04); 303 participants; moderate quality evidence). The regimens were also equally effective in reducing analgesic and narcotic use (34% versus 40%; RR 0.85, 95% CI 0.62 to 1.16; 271 participants), and in maintaining urinary continence (90% versus 87%; RR 1.03, 95% CI 0.96 to 1.1; 303 participants) in the short term (moderate quality evidence). In the other trial, split-course RT (30 Gy in eight fractions over two weeks) was no different from short-course RT in enhancing ambulation (70% versus 68%; RR 1.02, 95% CI 0.9 to 1.15; 276 participants); reducing analgesic and narcotic use (49% versus 38%; RR 1.27, 95% CI 0.96 to 1.67; 262 participants); and in maintaining urinary continence (87% versus 90%; RR 0.97, 0.93 to 1.02; 275 participants) in the short term (moderate quality evidence). Median survival was similar with the three RT regimens (four months). Local tumour recurrence may be more common with single-dose compared to short-course RT (6% versus 3%; RR 2.21, 95% CI 0.69 to 7.01; 303 participants) and with short-course compared to split-course RT (4% versus 0%; RR 0.1, 95% CI 0.01 to 1.72; 276 participants), but these differences were not statistically significant (low quality evidence). Gastrointestinal adverse effects were infrequent with the three RT regimens (moderate quality evidence), and serious adverse events or post-radiotherapy myelopathy were not noted.We did not find trials comparing radiotherapy schedules in people with MESCC and a good prognosis. Surgery plus radiotherapy compared to radiotherapyLaminectomy plus RT offered no advantage over RT in one small trial with 29 participants (very low quality evidence). In another trial that was stopped early for apparent benefit, decompressive surgery plus RT resulted in better ambulatory rates (84% versus 57%; RR 1.48, 95% CI 1.16 to 1.90; 101 participants, low quality evidence). Narcotic use may also be lower, and bladder control may also be maintained longer than with than RT in selected patients (low quality evidence). Median survival was longer after surgery (126 days versus 100 days), but the proportions surviving at one month (94% versus 86%; RR 1.09, 95% CI 0.96 to 1.24; 101 participants) did not differ significantly (low quality evidence). Serious adverse events were not noted. Significant benefits with surgery occurred only in people younger than 65 years. High dose corticosteroids compared to moderate dose or no corticosteroidsData from three small trials suggest that high-dose steroids may not differ from moderate-dose or no corticosteroids in enhancing ambulation (60% versus 55%; RR 1.08, 95% CI 0.81 to 1.45; 3 RCTs, 105 participants); survival over two years (11% versus 10%; RR 1.11, 95% CI 0.24 to 5.05; 1 RCT, 57 participants); pain reduction (78% versus 91%; RR 0.86, 95% CI 0.62 to 1.20; 1 RCT, 25 participants); or urinary continence (63% versus 53%; RR 1.18, 95% CI 0.66 to 2.13; 1 RCT, 34 participants; low quality evidence). Serious adverse effects were more frequent with high-dose corticosteroids (17% versus 0%; RR 8.02, 95% CI 1.03 to 62.37; 2 RCTs, 77 participants; moderate quality evidence).None of the trials reported satisfaction with care or quality of life in participants. AUTHORS' CONCLUSIONS Based on current evidence, ambulant adults with MESCC with stable spines and predicted survival of less than six months will probably benefit as much from one dose of radiation (8 Gy) as from two doses (16 Gy) or eight doses (30 Gy). We are unsure if a single dose is as effective as two or more doses in preventing local tumour recurrence. Laminectomy preceding radiotherapy may offer no benefits over radiotherapy alone. Decompressive surgery followed by radiotherapy may benefit ambulant and non-ambulant adults younger than 65 years of age, with poor prognostic factors for radiotherapy, a single area of compression, paraplegia for less than 48 hours, and a predicted survival of more than six months. We are uncertain whether high doses of corticosteroids offer any benefits over moderate doses or indeed no corticosteroids; but high-dose steroids probably significantly increases the risk of serious adverse effects. Early detection; and treatment based on neurological status, age and estimated survival, are crucial with all treatment modalities. Most of the evidence was of low quality. High-quality evidence from more trials is needed to clarify current uncertainties, and some studies are in progress.
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Affiliation(s)
- Reena George
- Christian Medical CollegePalliative Care UnitVelloreTamil NaduIndia632004
| | | | - Ramkumar Govindaraj
- Royal Adelaide HospitalDepartment of Radiation OncologyNorth TerraceAdelaideSAAustralia5000
| | - Ari G Chacko
- Christian Medical CollegeNeurosciencesVelloreTamil NaduIndia632002
| | - Prathap Tharyan
- Christian Medical CollegeCochrane South Asia, Prof. BV Moses Centre for Evidence‐Informed Healthcare and Health PolicyCarman Block II FloorCMC Campus, BagayamVelloreTamil NaduIndia632002
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Comparison of the Therapeutic Efficacy of Surgery with or without Adjuvant Radiotherapy versus Radiotherapy Alone for Metastatic Spinal Cord Compression: A Meta-Analysis. World Neurosurg 2015; 83:1066-73. [DOI: 10.1016/j.wneu.2014.12.039] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 12/15/2014] [Indexed: 11/20/2022]
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Abstract
Skeletal metastasis is a common cause of severe morbidity, reduction in quality of life (QOL) and often early mortality. Its prevalence is rising due to a higher rate of diagnosis, better systemic treatment, longer lives with the disease and higher disease burden rate. As people with cancer live longer and with rising sensitivity of body imaging and surveillance, the incidence of pathological fracture, metastatic epidural cord compression is rising and constitutes a challenge for the orthopedic surgeon to maintain their QOL. Metastatic disease is no longer a death sentence condemning patients to "terminal care." In the era of multidisciplinary care and effective systemic targeted and nontargeted therapy, patient expectations of QOL, even during palliative end of care period is high. We lay emphasis on proving the diagnosis of metastasis by biopsy and histopathology and discuss imaging modalities to help estimate fracture risk and map disease extent. This article discusses at length the evidence and decision-making process of various modalities to treat skeletal metastasis. The modalities range from radiation including image-guided, stereotactic and whole body radiation, systemic targeted or hormonal therapy, spinal decompression with or without stabilization, extended curettage with stabilization, resection in select cases with megaprosthetic or biological reconstruction, percutaneous procedures using radio frequency ablation, cementoplasties and discusses the role of emerging modalities like high frequency ultrasound-guided ablation, cryotherapy and whole body radionuclide therapy. The focus lies on the role of multidisciplinary care, which considers complex decisions on patient centric prognosis, comorbidities, cost, feasibility and expectations in order to maximize outcomes on QOL issues.
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Affiliation(s)
- Manish G Agarwal
- P.D. Hinduja National Hospital, Veer Savarkar Marg, Mahim, Mumbai, Maharashtra, India
| | - Prakash Nayak
- P.D. Hinduja National Hospital, Veer Savarkar Marg, Mahim, Mumbai, Maharashtra, India
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Rades D, Evers JN, Rudat V, Bajrovic A, Karstens JH, Schild SE. A validated score estimating ambulatory status following radiotherapy of elderly patients for metastatic spinal cord compression. BMC Cancer 2014; 14:589. [PMID: 25123656 PMCID: PMC4139608 DOI: 10.1186/1471-2407-14-589] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 08/08/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study was performed to develop a validated score predicting ambulatory status after radiotherapy (RT) alone for metastatic spinal cord compression (MSCC) in elderly patients. METHODS 1,129 elderly patients (≥65 years) were assigned to the test (N = 565) or validation group (N = 564). In the test group, nine pre-treatment factors (age, gender, tumor type, number of involved vertebrae, pre-RT ambulatory status, other bone metastases, visceral metastases, interval cancer diagnosis to RT, time developing motor deficits) and fractionation regimen were investigated. Factors significantly associated with post-RT ambulatory status on multivariate analysis were included in the score. The score for each factor was determined by dividing the post-RT ambulatory rate at 1 month (%) by 10. The total score represented the sum of these scores. RESULTS In the multivariate analysis of the test group, age, primary tumor type, pre-RT ambulatory status, visceral metastases, and time developing motor deficits were significantly associated with post-RT ambulatory status. Total scores were 19 to 41 points. In the test group, post-RT ambulatory rates were 5% for 19-25 points, 35% for 26-30 points, 80% for 31-34 points, and 98% for 35-41 points (p < 0.001). 6-month survival rates were 11%, 21%, 59% and 76%, respectively. In the validation group, post-RT ambulatory rates were 4%, 33%, 77% and 98%, respectively (p < 0.001). CONCLUSIONS Patients achieving 19-25 points had very poor functional outcomes and survival, and may receive single-fraction RT for pain relief. Selected patients with 26-34 points may benefit from additional surgery. Patients achieving ≥35 points achieved favorable results after RT alone.
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Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University of Lübeck, Ratzeburger Allee 160, D-23538 Lübeck, Germany.
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Prognostic role of the number of involved extraspinal organs in patients with metastatic spinal cord compression. Clin Neurol Neurosurg 2014; 118:12-5. [DOI: 10.1016/j.clineuro.2013.12.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 12/14/2013] [Indexed: 12/17/2022]
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A new prognostic factor for the survival of patients with renal cell carcinoma developing metastatic spinal cord compression. Strahlenther Onkol 2014; 190:667-70. [DOI: 10.1007/s00066-014-0616-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Accepted: 11/28/2013] [Indexed: 01/16/2023]
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Rief H, Heinhold RC, Petersen LC, Rieken S, Bruckner T, Moghaddam-Alvandi A, Debus J, Sterzing F. Neurological outcome after emergency radiotherapy in MSCC of patients with non-small cell lung cancer--a prospective trial. Radiat Oncol 2013; 8:297. [PMID: 24373638 PMCID: PMC3904469 DOI: 10.1186/1748-717x-8-297] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 12/26/2013] [Indexed: 11/30/2022] Open
Abstract
Background The aim of this trial was to investigate neurological outcome after emergency RT in MSCC of NSCLC patients with acute neurological deficit. Methods This pilot trial was prospective, non-randomized, and monocentre, ten patients were treated from July 2012 until June 2013. After onset of neurological symptoms RT was started within 12 hours. The neurological outcome was assessed at baseline, and six weeks after RT using the ASIA Impairment Scale (AIS). Results The results showed an improved neurological outcome in one patient (10%), one patient (10%) had a decreased, and five patients (50%) a constant outcome after six weeks. Three patients (30%) died within the first six weeks following RT, additional 4 patients (40%) died within 4 month due to tumor progression. Conclusion In this group of NSCLC patients we were able to show that emergency RT in MSCC with acute neurological deficit had no considerable benefit in neurological outcome. Therefore, short-course regime or best supportive care due to poor survival should be considered for these patients with additional distant metastases. Patients with favorable prognosis may be candidates for long-course RT. Trial Registration Clinical trial identifier NCT 02000518.
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Affiliation(s)
- Harald Rief
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany.
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Breast cancer patients with metastatic spinal cord compression. Strahlenther Onkol 2013; 190:283-6. [DOI: 10.1007/s00066-013-0473-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 09/16/2013] [Indexed: 11/26/2022]
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Prise en charge par radiothérapie des métastases osseuses et de leurs complications : les standards. Bull Cancer 2013; 100:1175-85. [DOI: 10.1684/bdc.2013.1845] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Rolle und Grenzen der Vertebro-/Kyphoplastie im Metastasenmanagement der Wirbelsäule. DER ORTHOPADE 2012; 41:640-6. [DOI: 10.1007/s00132-012-1909-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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