Multidisciplinary management of metastatic spine disease: initial symptom-directed management

Assessing combined effects of risk analysis index-revised (RAI-rev), malnutrition, and anemia on morbidity and mortality after spine surgery for metastatic spinal tumors

PURPOSE

This study evaluates the combined effects of frailty, anemia, and malnutrition on outcomes in spinal metastases patients.

METHODS

We conducted a retrospective cohort study using the 2011-2022 NSQIP database. Adult patients undergoing spinal surgery for spinal metastases were identified using CPT and ICD codes and stratified based on Risk Analysis Index-revised (RAI-rev) frailty status; frail patients were subdivided based on anemia and malnutrition status. Our primary outcomes were extended hospital length of stay (LOS), 30-day adverse events (AEs), non-routine discharge (NRD), and 30-day mortality. For each outcome, we fitted four nested multivariable logistic regression models (RAI-rev + anemia + malnutrition, RAI-rev + anemia, RAI-rev + malnutrition, and RAI-rev alone) and compared the incremental discrimination of each model using receiver operating characteristic (ROC) analysis.

RESULTS

1530 patients were stratified accordingly: 355 Frail Alone, 540 Frail + Anemic, 85 Frail + Malnourished, 407 Frail + Anemic + Malnourished, and 143 Not Frail. RAI-rev and malnourishment were risk factors for extended LOS ((RAI-rev: aOR 1.04, 95% CI 1.01-1.08; malnourishment: aOR 1.98, 95% CI 1.44-2.73)) and mortality (RAI-rev: aOR: 1.07, 95% CI 1.03-1.11; malnourishment: aOR: 2.37, 95% CI 1.50-3.75). RAI-rev (aOR 1.02, 95% CI 1.00-1.03) and anemia (aOR 2.06, 95% CI 1.50-2.84) independently predicted AEs and malnourishment predicted NRD (aOR 1.56, 95% CI 1.15-2.13). On ROC analysis, RAI-rev + anemic + malnourished superiorly predicted extended LOS (p = 0.021), AEs (p = 0.035), and mortality (p = 0.023) compared to RAI-rev. RAI-rev + malnourished outperformed RAI-rev in predicting extended LOS (p = 0.035) and mortality (p = 0.020). RAI-rev + anemic outperformed RAI-rev in predicting AEs (p = 0.032).

CONCLUSION

Our study suggests that RAI-rev-defined frailty combined with anemia and malnutrition is a superior predictor of outcomes in spinal metastases patients.

Integrated management of metastatic spinal tumors: current status and future directions

With improved cancer survivorship, the incidence of metastatic bone disease has risen, and metastatic spinal tumors (MSTs) have emerged as a common yet significant clinical challenge. These tumors may compromise the integrity of vertebral bodies leading to pathological fractures and neurological compromise from nerve root or spinal cord compression dramatically affecting the patient's quality of life. Despite the associated morbidity and mortality, optimal treatment strategies remain elusive. Here, in our review, we provide a comprehensive analysis of the contemporary MST treatment strategies, encompassing surgical interventions, advanced radiotherapy modalities, and evolving systemic therapies including chemotherapeutic and immunotherapeutic approaches. We critically evaluate each modality's development trajectory, clinical efficacy, therapeutic advantages, and inherent limitations. Our analysis reveals a definitive shift toward precision-guided radiotherapy and minimally invasive surgical techniques that balance therapeutic efficacy with reduced morbidity. These findings underscore the necessity for multidisciplinary management and highlight promising avenues for therapeutic innovation. As treatment paradigms evolve, integration of these advanced modalities offers new hope for this vulnerable patient population facing a challenging oncological complication.

Oncologic and Functional Outcomes After Stereotactic Body Radiation Therapy for High-Grade Malignant Spinal Cord Compression

Purpose

Although surgical decompression is the gold standard for metastatic epidural spinal cord compression (MESCC) from solid tumors, not all patients are candidates or undergo successful surgical Bilsky downgrading. We report oncologic and functional outcomes for patients treated with stereotactic body radiation therapy (SBRT) to high-grade MESCC.

Methods and Materials

Patients with Bilsky grade 2 to 3 MESCC from solid tumor metastases treated with SBRT at a single institution from 2009 to 2020 were retrospectively reviewed. Patients who received upfront surgery before SBRT were included only if postsurgical Bilsky grade remained ≥2. Neurologic examinations, magnetic resonance imaging, pain assessments, and analgesic usage were assessed every 3 to 4 months post-SBRT. Cumulative incidence of local recurrence was calculated with death as a competing risk, and overall survival was estimated by Kaplan-Meier.

Results

One hundred forty-three patients were included. The cumulative incidence of local recurrence was 5.1%, 7.5%, and 14.1% at 6, 12, and 24 months, respectively. At first post-SBRT imaging, 16.2% of patients with initial Bilsky grade 2 improved to grade 1, and 53.8% of patients were stable. Five of 13 patients (38.4%) with initial Bilsky grade 3 improved to grade 1 to 2. Pain response at 3 and 6 months post-SBRT was complete in 45.4% and 55.7%, partial in 26.9% and 13.1%, stable in 24.1% and 27.9%, and worse in 3.7% and 3.3% of patients, respectively. At 3 and 6 months after SBRT, 17.8% and 25.0% of patients had improved ambulatory status and 79.7% and 72.4% had stable status.

Conclusions

We report the largest series to date of patients with high-grade MESCC treated with SBRT. The excellent local control and functional outcomes suggest SBRT is a reasonable approach in inoperable patients or cases unable to be successfully surgically downgraded.

Surgical management of metastatic Hürthle cell carcinoma to the skull base, cortex, and spine: illustrative case

BACKGROUND

Hürthle cell carcinoma (HCC) is an unusual and aggressive variant of the follicular type of differentiated thyroid cancer (DTC), accounting for less than 3% of DTCs but posing the highest risk of metastasis. Brain metastases are uncommonly reported in the literature but pose a poor prognosis. The low rate of brain metastases from HCC coupled with ambiguous treatment protocols for the extracranial disease complicate successful disease management and definitive treatment strategy. The authors present the case of a patient with HCC metastasis to the skull base, cortex, and spine with recent tibial metastasis.

OBSERVATIONS

Despite the presence of metastasis to the cortex, skull base, and spine, the patient responded very well to radiation therapy, sellar mass resection, and cervical spine decompression and fixation and has made a remarkable recovery.

LESSONS

The authors' multidisciplinary approach to the patient's care, including a diverse team of specialists from oncology, neurosurgery, orthopedic surgery, radiology, endocrinology, and collaboration with clinical trial researchers, was fundamental to her successful outcome, demonstrating the utility of intersecting specialties in successful outcomes in neuro-oncological patient care.