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

Six-Month Survivorship Prediction in Spinal Metastatic Patients by Oncologists Shows Reliable Prognostication

STUDY DESIGN

A retrospective analysis of oncologist-provided prognoses vs actual survival outcomes of patients referred with Metastatic spinal cord compression (MSCC) to a supra-regional multidisciplinary team (MDT).

OBJECTIVES

Prognostic scoring systems, such as the revised Tokuhashi, are commonly used to help guide the treatment of MSCC. However, scoring systems do not accommodate for the improved outcomes of contemporary cancer therapy. Oncologist-provided prognoses play an important role in real world rapid decision making. There is a paucity of evidence assessing the accuracy of the oncologist-provided prognosis. We conducted a retrospective study to evaluate this.

METHODS

Data was captured between January 2015 and December 2018. Patients were split into 2 groups: Group 1 (prognosis estimated <6 months) and Group 2 (prognosis estimated >6 months). Median overall survival (mOS) and hazard ratio for death (HR) was assessed. Receiver operating characteristic (ROC) analysis was performed to assess the accuracy of the oncologist's prognosis.

RESULTS

829 patients were included. mOS in Group 1 was 5.8 months (95% CI 4.2-7.4 m), and in Group 2 mOS was not reached. Log rank test gave a Chi2 of 131 (P < .001). Cox regression analysis revealed a HR of .30 (P < .001). Area under the ROC curve was 78%.

CONCLUSIONS

Oncologist-provided prognosis is accurate in this cohort of unselected, consecutive MSCC patients. It reduced reliance on scoring systems that can become outdated. Given the rapid progress in cancer treatment, the oncologist's prognostic prediction is integral in efficient and effective MSCC management to help rapidly determine surgical candidacy.

Critical evaluation of the literature on decision-making in spinal metastases

Decision-making in patients with vertebral metastases is highly complex. Different factors of the patient, their cancer disease and treatment options are involved in it. Treatment schemes and strategies have been modified with the evolution of knowledge and treatment of disseminated oncological disease. This paper analyzes the bibliography that has been used for decision-making in the last three decades, as well as the evolution to the schemes that we could consider contemporary.

Predictors of Survival After Emergent Surgical Decompression for Acutely Presenting Spinal Metastasis

BACKGROUND

Metastatic spinal tumors represent 90% of spinal masses and present variably with slow progression and/or rapid symptomatic worsening. Several prognostic scoring systems have been proposed. However, patients presenting acutely and requiring emergent surgery represent a unique subset of patients with different prognostic indicators.

METHODS

All cases of symptomatic spinal metastases requiring emergent surgery between 2010 and 2021 at our institution were retrospectively reviewed. Survival time from date of surgery to death or last follow-up was calculated. Patients were stratified on the basis of survival for more or less than 6 months after surgery. Multivariate logistic regression was used to develop a model predicting probability of mortality at 6 months.

RESULTS

Forty-four patients satisfied inclusion criteria. Mean age at presentation was 60.4 ± 11.8 years with a median survival time of 6.5 [1.9-19.5 interquartile range] months. On univariate analysis, higher Tokuhashi score, Karnofksy performance scale (KPS), and lower modified McCormick scale were significantly associated with 6-month survival (P = 0.018, P < 0.001, P = 0.002, respectively). Preoperative American Spinal Injury Association grade and Spine Instability Neoplastic Score scores were not associated with survival. Multivariate analysis found KPS significantly correlated with survival (0.91 odds ratio, 0.85-0.98, 95% confidence interval, P = 0.011) at 6 months and that a stepwise regression model derived from KPS and Tokuhashi score demonstrated the highest predictive accuracy for 6-month survival (area under the curve = 0.843, Akaike information criterion = 37.1, P = 0.0039).

CONCLUSIONS

KPS and Tokuhashi scores most strongly correlated with 6-month survival in patients presenting with acutely symptomatic spinal metastases. These findings underscore the importance of baseline functional status and overall tumor burden on survival and may be useful in preoperative evaluation and surgical decision making for acutely presenting spinal metastases.

[Translated article] Critical evaluation of the literature on decision-making in spinal metastases

Decision-making in patients with vertebral metastases is highly complex. Different factors of the patient, their cancer disease and treatment options are involved in it. Treatment schemes and strategies have been modified with the evolution of knowledge and treatment of disseminated oncological disease. This paper analyzes the bibliography that has been used for decision-making in the last three decades, as well as the evolution to the schemes that we could consider contemporary.

Spinal metastases of bronchopulmonary cancer: Role of spinal surgery and value of prognostic scores (Modified Tokuhashi and Tomita)

INTRODUCTION

Bone metastasis is frequent in bronchopulmonary cancer. We report a series of 52 patients, and analyze indications and the efficacy of surgery.

MATERIALS AND METHODS

We retrospectively studied the records of 52 patients operated on for spinal metastases of bronchopulmonary cancer over a 6-year period from January 2009 to December 2014 in the neurosurgery department of the North Hospital of Marseille, France.

RESULTS

Mean age was 63.6 years; with a sex ratio of 3:1 (M:F). Spinal pain associated with vertebral fracture and spinal cord compression was the most frequent clinical presentation (59.6%). SINS score was ≥7 in 78.9% of cases. Karnofski Performance Status was average in 67.4% of cases. Predicted survival beyond 12 months was zero according to the modified Tokuhashi score. The surgical indication was essentially palliative. Evolution showed regression of pain in 84.6% of cases, and stabilization and improvement in motor deficit in 80.6%. Median postoperative survival was 16 months.

CONCLUSION

Our results highlight the interest of surgery for pain relief, spinal stabilization and improvement in neurological function in patients with spinal metastases of bronchopulmonary cancer, and the unreliability of predictive survival scores.

Thoracic Spinal Cord Compression Secondary to Metastatic Papillary Thyroid Carcinoma: An Unusual Oncological Phenomenon

Hematogenous spread is fairly an unusual feature for papillary thyroid carcinoma (PTC) in comparison to follicular thyroid carcinoma (FTC). Thoracic spinal metastasis with complicating cord compression is an even rarer manifestation of PTC that was reported in a limited number of cases in the literature. Herein we present a 65-year-old female with a history of PTC on current radiotherapy, status post attempted surgery due to significant tumor burden and intraoperative bleeding, presented with a one-week history of rapidly progressive bilateral lower extremities weakness. Physical examination revealed paraplegia of both lower extremities with areflexia and a sensory level equivalent to the upper thoracic vertebrae. Urgent imaging depicted destructive epidural lesions at T1-T3 vertebrae with thoracic cord compression. Emergent laminectomy and debulking of these lesions were undertaken. Histopathological examination confirmed metastatic PTC. The patient proceeded to further treatment with radiotherapy following her successful neurological recovery. Thoracic vertebral metastasis is an unusual oncological phenomenon of PTC. Metastatic PTC should be considered in patients with a current or remote history of PTC who present with thoracic cord compression. Our case demonstrates that multidisciplinary management is the key to achieving a better outcome for metastatic PTC with thoracic cord compression.

Does the Region of the Spine Involved with Metastatic Tumor Affect Outcomes of Surgical Treatments?

OBJECTIVE

Spinal metastases occur primarily in the thoracic spine (50%-60%), less commonly in the lumbar (30%-35%), and, infrequently, in the cervical spine (10%-15%). There has been only 1 study with a limited population comparing the postoperative outcome among cervical, thoracic, and lumbar spine metastasis. The aim of this study is to identify whether the region of surgically treated spinal metastasis affects postoperative outcomes.

METHODS

A retrospective study of patients with spinal metastasis was performed. The collected data were as follows: age, gender, smoking history, tumor histology, revised Tokuhashi score, preoperative and postoperative American Spinal Injury Association score, region of spinal metastasis, ambulatory status, surgical approach, surgery time, blood loss, complications, length of hospital stay, postoperative pain relief, postoperative adjuvant therapy, and survival. Data were analyzed to identify the factors affecting the survival and postoperative functional outcome.

RESULTS

We studied 191 patients with spinal metastasis including 47 cervical spine metastases, 96 thoracic spine metastases, and 48 lumbar spine metastases, with a mean age of 60.91 ± 9.72 years. The overall median survival was 7 months (95% confidence interval, 2.9-20.63 months). Univariate analysis showed that region of the spine involved with metastasis did not significantly affect the survival and postoperative motor function improvement. Multivariate analysis showed that revised Tokuhashi score, postoperative radiotherapy, and postoperative chemotherapy were independent factors affecting survival. The rate of 30-day complications among patients with different regions of spine metastasis did not reach significance.

CONCLUSIONS

The postoperative outcomes of patients undergoing surgery for metastases are not affected by the region of the spine.

UNKNOWN PRIMARY TUMOR SITES IN SPINAL METASTASIS

ABSTRACT Objective: The goal of the study was to report the prevalence of spinal metastasis with unknown primary tumor, clinical features, treatment results and patient survival. Methods: A retrospective evaluation of 103 patients with spinal metastasis and epidural compression, who underwent surgical treatment between March 2009 and August 2015. The prevalence of metastatic spinal tumor with unknown primary tumor was evaluated, as well clinical features, survival and treatment results. Results: Of 103 patients with spinal metastasis and epidural compression, seven patients (6.8%) with unknown primary tumor site were identified; five (71.4%) male and two (28.6%) female, with ages ranging from 37 to 67 years (50.7 years). The metastasis was located in the thoracic spine in six of the patients (85.7%) and in the cervical spine in one (14.3%). The mean survival time was 44.8 days. Conclusion: Spinal metastasis with unknown primary tumor was found in 6.8% of patients. The prognosis and outcomes were poor, and patients had poor survival rates. Level of evidence III; Experimental study.

A Novel Prediction Tool for Overall Survival of Patients Living with Spinal Metastatic Disease

OBJECTIVE

To identify the significant prognostic factors for overall survival in patients with spinal metastases and to establish an online widget for predicting survival with an interactive visual approach.

METHODS

Patients operated for spinal metastases between 2010 and 2018 were retrospectively enrolled and were randomly divided into training and validation samples with a ratio of 7:3. Patients' characteristics were analyzed with univariate and multivariate Cox analyses to identify independent prognostic factors basing on the training sample. A shiny web tool was developed by transforming the fitted multivariable Cox model into a visual interface. Time-dependent area under the curve plot and calibration curve were generated to assess the discrimination ability and consistency of the novel model, both for the training and validation samples.

RESULTS

A total of 265 consecutive patients were finally included, with 185 in the training sample and 80 in the validation sample. The primary tumor types, lesion site of metastasis, visceral metastasis, Frankel grade, operation category, number of surgical segments, and the preoperative percentage of lymphocyte were demonstrated to be significantly associated with overall survival. A novel shiny model (https://yang1209xg.shinyapps.io/predictspinalmetastasis/) that could provide predicted survival curve and median survival time was established, with favorable discrimination ability and consistency between predicted and actual survival both in internal and external data, according to time-dependent area under the curve plots and calibration curves.

CONCLUSIONS

A user-friendly shiny app with favorable discrimination ability and consistency was released online for predicting the survival of patients with spinal metastases. A continuous survival curve and the predicted median survival time are available to guide the treatment planning.

Necessity of Bony Fusion After Surgical Treatment of Metastatic Spine Tumors

INTRODUCTION

The role of bony fusion in influencing patient outcome and surgical revision rates in the treatment of metastatic spine disease is poorly defined. The goals of this study were, therefore, to evaluate the effect of fusion on revision surgery as well as on overall survival (OS) and functional status in patients with metastatic disease of the spine.

METHODS

A retrospective cohort study of a prospective database at a major cancer center was conducted. A total of 25 patients who met the inclusion criteria from January 2010 to December 2015 were included. Functional status, patient and tumor characteristics, fusion status, and survival were analyzed, and regression analyses were done. Bony fusion was classified as either present (seen across a minimum of three levels and crossing the tumor site) or absent as evidenced through CT images at minimum of 1-year postoperatively.

RESULTS

Twenty-five subjects with 28 surgical sites met the eligibility criteria to be included in this study cohort. Five surgical sites were found to have evidence of fusion on CT scans at 1 year after surgery, and 23 sites had no evidence of bridging fusion. No differences were found between the two groups in terms of OS, and ambulatory status (P > 0.10). Multivariate analysis did not reveal any specific factors affecting fusion. Mean follow-up was 23.7 months.

DISCUSSION

The lack of bony fusion is not an independent predictor of the need for revision surgery. The lack of bony fusion in patients with metastatic disease of the spine does not appear to negatively affect their OS or their ambulatory status. A discussion of factors affecting fusion is complex, and there are other factors that may also play a role. Large multicenter trials are needed to corroborate the preliminary findings seen in this complex patient cohort.

Prognostic factors for overall survival in patients with spinal metastasis secondary to prostate cancer: a systematic review and meta-analysis

Background

To guide the selection of treatments for spinal metastases, the expected survival time is one of the most important determinants. Few scoring systems are fully applicable for spinal metastasis secondary to prostate cancer (PCa). This study aimed to identify the independent factors to predict the overall survival (OS) of patients with spinal metastases from PCa.

Methods

The PubMed, Embase and CENTRAL were retrieved by two reviewers independently, to identify studies analyzed the prognostic effect of different factors in spinal metastasis from PCa. A systematic review and quantitative meta-analysis was conducted with hazard ratio (HR) and 95% confidence interval (95%CI) as the effect size.

Results

A total of 12 retrospective cohort studies (1566 patients) were eligible for qualitative synthesis and 10 for quantitative meta-analyses. The OS was significantly influenced by performance status, visceral metastasis, ambulatory status and time from PCa diagnosis in more than half of the available studies. The meta-analyses demonstrated that OS was significantly influenced by visceral metastasis (HR = 2.24, 95%CI:1.53–3.27, p < 0.001), pre-treatment ambulatory status (HR = 2.64, 95%CI:1.82–3.83, p < 0.001), KPS (HR = 4.45, 95%CI:2.01–9.85, p < 0.001), ECOG (HR = 2.96, 95%CI:2.02–4.35, p < 0.001), extraspinal bone metastasis (HR = 2.04, 95%CI:1.13–3.68, p = 0.018), time developing motor deficit (HR = 1.57, 95%CI:1.30–1.88, p < 0.001) and time from PCa diagnosis (HR = 1.37, 95%CI:1.17–1.59, p < 0.001).

Conclusions

Visceral metastasis, ambulatory status, extraspinal bone metastasis, performance status, time developing motor deficit and time interval from primary tumor diagnosis were significantly associated with the OS for spinal metastasis from PCa. When selecting the treatment modality, clinicians should fully consider the patients’ systematic status based on all potential prognostic factors.

Level of evidence

I Meta-analysis.

Prognostic effect of factors involved in revised Tokuhashi score system for patients with spinal metastases: a systematic review and Meta-analysis

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.

New Predictive Index for Survival in Symptomatic Spinal Metastases

OBJECTIVE

Patients with spinal metastases have broad variability in morbidity, mortality, and survival. Existing prognostic scoring systems have limited predictive value. Our aim is, given recent advances in surgical and medical care for patients with cancer and spinal metastases, to develop a new survival index with superior prognostic value.

METHODS

We completed a retrospective analysis on 77 patients who received surgery for metastatic tumors to the spine, of patient factors like pathologic subtype, age, neurologic examination, type of surgical procedure, Hauser Ambulation Index, and a novel scoring system for degree of tumor burden in several organ systems, among others. A survival index will be derived from the patient factors that, when measured preintervention, best predicted survival post intervention.

RESULTS

Although primary organ or pathologic type was not predictive of survival for patients with metastatic disease in this population, the degree of lung tumor burden (LTB) and preoperative Hauser Ambulation Index were predictive of survival. After a multivariable analysis of >20 different patient factors, the Jenkins Survival Index (JSI, a 0-21 scale) was constructed using a machine-learning system as the sum of the HAI (0-9 scale) and LTB score (0-3 scale) multiplied by 4 (JSI = HAI + 4 · LTB, Rho = -0.588, P < 0.0001). The JSI had a positive predictive value of 92% compared with 54.1% and 56.9% for Tokuhashi and Tomita scales, respectively.

CONCLUSIONS

The JSI predicts in a meaningful way survival outcomes for patients symptomatic from spinal metastases, which will be of value to oncologists and other clinicians treating patients with metastatic disease.

Predicting survival for metastatic spine disease: a comparison of nine scoring systems

BACKGROUND CONTEXT

Despite advances in spinal oncology, research in patient-based prognostic calculators for metastatic spine disease is lacking. Much of the literature in this area investigates the general predictive accuracy of scoring systems in heterogeneous populations, with few studies considering the accuracy of scoring systems based on patient specifics such as type of primary tumor.

PURPOSE

The aim of the present study was to compare the ability of widespread scoring systems to estimate both overall survival at various time points and tumor-specific survival for patients undergoing surgical treatment for metastatic spine disease in order to provide surgeons with information to determine the most appropriate scoring system for a specific patient and timeline.

STUDY DESIGN

This is a retrospective study.

PATIENT SAMPLE

Patients who underwent surgical resection for metastatic spine disease at a single institution were included.

OUTCOME MEASURES

Areas under the receiver operating characteristic curves were generated from comparison of actual survival of patients and survival as predicted by application of prevalent scoring systems.

METHODS

A preoperative score for all 176 patients was retrospectively calculated utilizing the Skeletal Oncology Research Group (SORG) Classic Scoring Algorithm, SORG Nomogram, original Tokuhashi, revised Tokuhashi, Tomita, original Bauer, modified Bauer, Katagiri, and van der Linden scoring systems. Univariate and multivariate Cox proportional hazard models were constructed to assess the association of patient variables with survival. Receiver operating characteristic analysis modeling was utilized to quantify the accuracy of each test at different end points and for different primary tumor subgroups. No funds were received in support of this work. The authors have no conflicts of interest to disclose.

RESULTS

Among all patients surgically treated for metastatic spine disease, the SORG Nomogram demonstrated the highest accuracy at predicting 30-day (area under the curve [AUC] 0.81) and 90-day (AUC 0.70) survival after surgery. The original Tokuhashi was the most accurate at predicting 365-day survival (AUC 0.78). Multivariate analysis demonstrated multiple preoperative factors strongly associated with survival after surgery for spinal metastasis. The accuracy of each scoring system in determining survival probability relative to primary tumor etiology and time elapsed since surgery was assessed.

CONCLUSIONS

Among the nine scoring systems assessed, the present study determined the most accurate scoring system for short-term (30-day), intermediate (90-day), and long-term (365-day) survival, relative to primary tumor etiology. The findings of the present study may be utilized by surgeons in a personalized effort to select the most appropriate scoring system for a given patient.

Prognostic Discrepancy on Overall Survival Between Ambulatory and Nonambulatory Patients with Metastatic Spinal Cord Compression

BACKGROUND

Contradictory results have been reported regarding the prognostic effect of ambulatory status in patients with metastatic spinal cord compression (MSCC). The aim of this study was to investigate whether ambulatory status is a significant predictor of overall survival in patients with MSCC and to distinguish the differences of predictors between patients who were ambulatory and those who were not ambulatory before operation.

METHODS

Three clinical centers were retrospectively reviewed to identify patients operated on for MSCC between 2005 and 2015. Fourteen prognostic factors were analyzed using Kaplan-Meier survival curves, univariate log-rank test, and multivariate Cox hazard regression model for the whole cohort and the subgroups of ambulatory and nonambulatory patients.

RESULTS

In all, 169 patients were consecutively enrolled. Their mean age was 59.6 ± 10.5 years (range, 18-84 years). The median survival time in the whole cohort was 7.0 ± 0.5 months, whereas it was 7.0 ± 0.8 months and 5.0 ± 1.3 months in ambulatory and nonambulatory patients, respectively. Multivariate Cox regression analysis showed that ambulatory status was not a significant predictor of overall survival (P = 0.266), but primary tumor type and Karnofsky performance status were independent predictors of overall survival for the whole cohort. Primary tumor and metastatic site were significantly associated with survival in ambulatory patients. Gender and Karnofsky performance status were associated with survival in nonambulatory patients.

CONCLUSIONS

Ambulatory status was not shown to predict the prognosis of patients with MSCC. prognostic factors should be distinguished between ambulatory and nonambulatory patients when choosing a therapeutic modality.

Is Ambulatory Status a Prognostic Factor of Survival in Patients with Spinal Metastases? An Exploratory Meta-analysis

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.

Prognostic factors in patients with metastatic spine tumors derived from lung cancer-a novel scoring system for predicting life expectancy

BACKGROUND

Recently, molecule-targeting and bone-modifying agents have improved the treatment outcomes of lung cancer-derived metastatic spine tumors. Therefore, the prognostic factors for such tumors were examined, and novel scoring systems for predicting the life expectancy of patients with such tumors were proposed.

METHODS

In 207 patients with lung cancer-derived metastatic spine tumors (surgery 49; conservative therapy 158), we retrospectively examined the factors that influenced the post-treatment survival time (age, sex, the affected site, pathology, general condition, the number of extraspinal bone metastases, the number of spinal metastases, the presence/absence of major internal organ metastasis, paralysis state, the total Tokuhashi score, the serum alkaline phosphatase level, the serum carcinoembryonic antigen level, molecule-targeting drug treatment, and bone-modifying agent treatment). Based on the results, we devised novel scoring systems for predicting the prognosis of such patients.

RESULTS

Univariate analyses showed that the pathology of the primary lung tumor, the patient's general condition and paralysis state, and the presence/absence of molecule-targeting drug treatment significantly influenced survival. We performed a Cox regression analysis of these four factors and developed criteria for a novel scoring system based on the patient's general condition and paralysis state, which exhibited significance in the regression analysis. A retrospective review indicated that the consistency rate between predicted life expectancy and actual survival was 67.3%. When criteria based on the four factors that exhibited significance in the univariate analyses were adopted, the consistency rate was 76.2%.

CONCLUSION

The patient's general condition and paralysis state, the pathology of the primary lung tumor, and molecule-targeting drug treatment influenced survival among patients with lung cancer-derived metastatic spine tumors. Novel scoring systems based on these four factors were proposed.

Survival Outcomes and Factors Associated with Revision Surgery for Metastatic Disease of the Spine

Study Design

Retrospective review of a prospective database.

Objective

Certain subset of patients undergoing surgical treatment for spinal metastasis will require a revision surgery in their disease course; however, factors predictive of revision surgery and survival outcomes are largely unknown. The goal of this study is to report on survival outcomes as well as factors predictive of revision surgery in this unique patient population.

Methods

A total of 55 patients who met the inclusion criteria were included from January 2010 to December 2015. Twelve (22%) of these patients underwent a revision surgery. Patient and tumor characteristics were summarized and survival outcomes were evaluated using Kaplan-Meier methods and Cox proportional hazards regression.

Results

Both the revision and the nonrevision groups were similarly matched with respect to spine disease burden, neurological status at time of initial presentation, primary malignancy types, and the use of adjuvant treatment modalities. Tumor progression (66.7%) was the most common reason for necessitating a revision followed by nonunion (16.7%), wound dehiscence (8.3%), and construct failure (8.3%). Following multivariate model selection procedures, smokers were found to have 3.5 times increased odds of undergoing revision compared to nonsmokers (p = 0.05). Analysis of survival curves showed that the median survival in the revision group was 3.0 years (95% CI: 1.5, 4.1), while the median survival in the nonrevision group was 1.5 years (95% CI: 1.1, 2.3; log-rank test, p = 0.105).

Conclusion

Despite aggressive treatment, tumor progression is the most common reason for revision surgery. Smoking is an independent risk factor for revision. Revision surgery should be considered in patients when indicated as it does not appear to detrimentally affect survival.

Classification and scoring systems for metastatic spine tumors: a literature review

Introduction

Accurate evaluation of metastasis and life prognosis is essential for selecting a suitable therapeutic strategy for metastatic spine tumors owing to limitations in treatment options. For this purpose, various classification, evaluation, and scoring systems have been developed.

Methods

Classification, evaluation, and scoring systems for metastatic spine tumors reported to date were identified by performing a literature search on PubMed. We reviewed the most cited classifications and scorings before 2009, and all classifications and scorings reported after 2010 from the search results.

Results

Six classifications and 23 scorings were reviewed. The classification/evaluation methods are divided into 1) anatomical classification/evaluation methods, 2) evaluation methods for neurological symptoms/instability, and 3) scoring systems for predicting life expectancy. The first 2 were useful for the planning and evaluation of surgical indications. Scoring systems for life prognosis also permitted rough prediction of the outcomes and were useful for the selection of a suitable treatment. However, variation of the patient background, diversity of adopted prognostic factors, and the absence of scoring systems that could predict the outcome with an accuracy of 90% or higher introduced some limitations.

Conclusion

The identified classification, evaluation, and scoring systems have been generally useful for treatment strategies. However, we emphasize the necessity of multidisciplinary development and revision of classification and evaluation methods to adapt to the prolongation of survival associated with increased diversity and improvement of treatment options.

Reliability of Tokuhashi Score to Predict Prognosis: Comparison of 117 Patients

BACKGROUND

Spinal metastatic disease compromises the quality of life and prognosis of the patients. Prognosis is an important factor for the decision-making process and needs to be precise in order to adjust the intensity of therapy. The Tokuhashi score is a universal instrument to determine the prognosis. The objective was to analyze the effectiveness of the Tokuhashi score in determining the prognosis of the patients with spine metastasis by comparing the expected survival time from the Tokuhashi score with the survival time observed among surgical patients.

METHODS

This retrospective study was performed from October 2008 to October 2015. The inclusion criteria were symptomatic patients with spinal metastasis who underwent spinal cord decompression and had a minimum of 1-year follow-up. The exclusion criteria were patients without histologic confirmation and were lost to follow-up. The Tokuhashi score was applied, and once the expected survival was defined, it was compared with the survival time observed in the follow-up.

RESULTS

The sample studied was 117 patients. The commonly female (58%) and breast spinal metastasis was often observed (25.6%). The patients were followed for a minimum period of 12 months. The actual survival was beyond that estimated by the Tokuhashi score (P < 0.05).

CONCLUSION

The Tokuhashi score was not reliable to predict the prognosis. Patients with lower scores that surgical treatment was not recommended by the Tokuhashi score had better quality of life and longer survival after surgery. Tokuhashi score is not a precise tool to establish the best therapy and survival in patients with spinal metastasis.

Spinal Metastasis of Unknown Primary Accompanied by Neurologic Deficit or Vertebral Instability

BACKGROUND AND OBJECTIVE

Spinal bone metastases are common. They are mostly localized to the lumbar, thoracic, and cervical spine. The most common primaries to result in spinal metastases include lung, breast, and prostate carcinomas in adults as opposed to leukemia, Ewing sarcoma, rhabdomyosarcoma, and neuroblastoma in children. In patients diagnosed with cancer, bone metastases are found in 40% and spinal metastases in 10%. In this study, we reviewed 25 patients diagnosed with a spinal metastasis of unknown primary who presented with low back pain or acute-onset neurologic deficits and underwent operative treatment.

METHODS

The retrospective study included 25 patients with a spinal metastasis of unknown primary who presented to our clinic with acute-onset vertebral fracture or neurologic deficit. Statistical descriptions were obtained for each patient. Survival analysis was performed using the Kaplan-Meier method.

RESULTS

The 25 patients included 17 men (68%) and 8 women (32%), with a mean age of 55 years (range, 14-81 years). Eleven patients (44%) presented with varying degrees of motor deficits ranging from flaccid paralysis to paraplegia. Motor deficits were completely reversed in 4 patients postoperatively. The tumors were localized to the upper thoracic spine (T1-4) in 2 patients, in the midthoracic spine (T5-8) in 2 patients, in the lower thoracic spine (T9-12) in 8 patients, in the cervical 7 in 1 patient, and in the lumbar spine in 12 patients. In 10 patients, the tumor affected multiple spinal regions. Nonosseous tumors were not present in 10 patients. Ten patients had an extradural tumor. Costal involvement was detected in 2 patients. The tumors were pathologically identified as lung cancer (n = 3), lymphoma (n = 5), breast cancer (n = 3), gastric cancer (n = 2), liver cancer (n = 2), prostate cancer (n = 2), renal cell carcinoma (n = 2), malignant melanoma (n = 1), plasmacytoma (n = 1), bladder cancer (n = 1), paraganglioma (n = 1), Ewing sarcoma (n = 1), and yolk sac carcinoma (n = 1). Posterior instrumentation was performed in patients with instability. In addition, decompression was performed in patients with neurologic deficit.

CONCLUSIONS

Considering that 10% of patients with cancer are diagnosed by vertebral metastasis, presence of malignancy should be suspected and a detailed examination should be performed in patients presenting with vertebral fractures caused by no or minor trauma. Moreover, in patients presenting with neurologic deficit, soft tissue metastases leading to spinal cord compression should be kept in mind and further examinations should be promptly administered.

Accuracy of Preoperative Scoring Systems for the Prognostication and Treatment of Patients with Spinal Metastases

Background

In patients with spinal metastatic disease, survival prognosis is a key consideration in selection for surgery and determining the extent of treatment. Individual survival prediction however remains difficult. We sought to validate the prognostic accuracy of seven preoperative scoring systems.

Methods

61 patients surgically treated for spinal metastases were retrospectively reviewed. Preoperative scores were calculated for Tokuhashi, Revised Tokuhashi, Bauer, Modified Bauer, Sioutos, Tomita, and van der Linden scoring systems. Prognostic value was determined by comparison of predicted and actual survival.

Results

The Revised Tokuhashi and Modified Bauer scoring systems had the best survival predictive accuracy. Rate of agreement for survival prognosis was the greatest for the Modified Bauer score. There was a significant difference in survival of the prognostic groups for all but the van der Linden score, being most significant for the Revised Tokuhashi, Bauer, Modified Bauer, and Tomita scoring systems (p ≤ 0.001).

Conclusion

Overall, the scoring systems are accurate at differentiating patients into short-, intermediate-, and long-term survivors. More precise prediction of actual survival is limited and the decision for or against surgery should never be based on survival prognostication alone but should take into account symptoms such as neurological deficit or pain from pathological fracture and instability.

Metastatic spinal cord compression as the first sign of malignancy

Background and purpose - Metastatic spinal cord compression (MSCC) as the initial manifestation of malignancy (IMM) limits the time for diagnostic workup; most often, treatment is required before the final primary tumor diagnosis. We evaluated neurological outcome, complications, survival, and the manner of diagnosing the primary tumor in patients who were operated for MSCC as the IMM. Patients and methods - Records of 69 consecutive patients (51 men) who underwent surgery for MSCC as the IMM were reviewed. The patients had no history of cancer when they presented with pain (n = 2) and/or neurological symptoms (n = 67). Results - The primary tumor was identified in 59 patients. In 10 patients, no specific diagnosis could be established, and they were therefore defined as having cancer of unknown primary tumor (CUP). At the end of the study, 16 patients were still alive (median follow-up 2.5 years). The overall survival time was 20 months. Patients with CUP had the shortest survival (3.5 months) whereas patients with prostate cancer (6 years) and myeloma (5 years) had the longest survival. 20 of the 39 patients who were non-ambulatory preoperatively regained walking ability, and 29 of the 30 ambulatory patients preoperatively retained their walking ability 1 month postoperatively. 15 of the 69 patients suffered from a total of 20 complications within 1 month postoperatively. Interpretation - Postoperative survival with MSCC as the IMM depends on the type of primary tumor. Surgery in these patients maintains and improves ambulatory function.

Hardware failure in patients with metastatic cancer to the spine

BACKGROUND

The spine is the most common site of skeletal metastases, affecting approximately 30% of individuals with cancer. The aim of surgical treatment for metastatic spine disease is generally palliative to address pain and/or neurologic compromise, significantly improving patients' quality of life. Patients with metastatic spine disease, however, represent a vulnerable cohort and may have comorbidities or previous treatments that impair the structural integrity of spinal hardware. As such, identifying factors that may contribute to hardware failure is an essential component in treating individuals with metastatic spine disease.

OBJECTIVE

The aim of this study was to identify pre-operative risk factors associated with hardware failure in patients undergoing surgical treatment for metastatic spine disease.

METHODS

A retrospective cohort study was conducted to include patients surgically treated for metastatic spine tumors between 2003 and 2013, at a single institution. A univariate analysis was initially performed to identify associated factors. Any associated factor with a p-value <0.20 was included in the multivariate analysis.

RESULTS

3 patients (1.9%), of the 159 patients included in the study, had failure of the spine instrumentation. 1 patient had metastatic prostate cancer, and 2 had metastatic breast cancer. Patient demographics, co-morbidities, tumor location, and primary tumor etiology were not found to be statistically significant, with respect to hardware failure. Predictive factors included in the multivariate model were other bone metastasis, visceral metastasis, brain metastasis, Modified Rankin scale, previous systemic chemotherapy, previous radiation to the spine, and mean survival. Previous radiation to the spine was the only factor to be significantly associated (p=0.029), present in all three patients with hardware failure. Of note, there was a trend indicating that patients with longer life expectancies were more likely to experience hardware failure (mean survival of 16.7months in non-failure cohort vs. 33months in failure cohort), though this did not achieve statistical significance due to the limited sample size of patients with hardware failure.

CONCLUSION

Hardware failure is a risk for all patients who undergo instrumentation following resection for metastatic spine tumors. This study identified that pre-operative radiation may increase the risk for hardware failure in this population.

Sternal metastasis - the forgotten column and its effect on thoracic spine stability

Sternal metastases are not studied extensively in the literature. There is a paucity of information on their role in metastatic disease. The concept of the fourth column was described by Berg in 1993, and has been proven in case report, clinically and biomechanical studies. The role of the sternum as a support to the thoracic spine is well documented in the trauma patients, but not much is known about its role in cancer patients. This review examines what is known on the role of the fourth column. Following this we have identified two likely scenarios that sternal metastases may impact management: (1) sternal pathological fracture increases the mobility of the semi-rigid thorax with the loss of the biomechanical support of the sternum-rib-thoracic spine complex; and (2) a sternal metastasis increases the risk of fracture, and while being medical treated the thoracic spine should be monitored for acute kyphosis and neurological injury secondarily to the insufficiency of the fourth column.

[Surgical treatment of spinal bone metastases]

Surgery for metastatic tumor is usually a palliative surgery, especially for spinal metastases, due to their anatomical localization. Surgical procedure should be accurately established to have simple outcomes and to start adjuvant treatment as soon as clinically possible. Therapeutic strategy should proceed after multidisciplinary consultation meeting (RCP). The main risk of spinal bone metastases is neurological, hence this surgery should be most commonly preventive. Its main objective is to improve patient's quality of life.

Decompression surgery for spinal metastases: a systematic review

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.

STATISTICAL ANALYSIS OF THE CASUISTRY OF A SAMPLE OF METASTATIC DISEASE IN THE SPINE

ABSTRACT Objective: The objective of this study is to present demographic data on the occurrence of spinal metastases in the service where the work was performed and to investigate the reliability of the modified Tokuhashi score in the decision making in patients with metastatic spinal cancer. Methods: We conducted a review of medical records of all cases of vertebral bone metastasis, confirmed by anatomopathological examination, from January 2009 to June 2012. Data review included demographic details, origin of the primary cancer, duration of symptoms, localization of metastases, Karnofsky performance scale and survival based on modified Tokuhashi score. We divided patients into three groups. Group A included patients with life expectancy of less than six months, group B included patients with life expectancy of between six and 12 months, and group C included patients with a life expectancy of more than 12 months. We compared the calculated survival with the current survival in the three groups with all patients followed-up to a minimum of 1 year or until death. Results: The predict survival in group A was 63.6% according to the modified Tokuhashi score, albeit group B had only 30% agreement. Conclusions: For patients in group A, the agreement rate of patient survival was better (63.4%) than that observed in patients in group B (30%). Our sample had no patient classified as group C.

The 100 most cited articles in metastatic spine disease

OBJECTIVE

Despite the growing neurosurgical literature, a subset of pioneering studies have significantly impacted the field of metastatic spine disease. The purpose of this study was to identify and analyze the 100 most frequently cited articles in the field.

METHODS

A keyword search using the Thomson Reuters Web of Science was conducted to identify articles relevant to the field of metastatic spine disease. The results were filtered based on title and abstract analysis to identify the 100 most cited articles. Statistical analysis was used to characterize journal frequency, past and current citations, citation distribution over time, and author frequency.

RESULTS

The total number of citations for the final 100 articles ranged from 74 to 1169. Articles selected for the final list were published between 1940 and 2009. The years in which the greatest numbers of top-100 studies were published were 1990 and 2005, and the greatest number of citations occurred in 2012. The majority of articles were published in the journals Spine (15), Cancer (11), and the Journal of Neurosurgery (9). Forty-four individuals were listed as authors on 2 articles, 9 were listed as authors on 3 articles, and 2 were listed as authors on 4 articles in the top 100 list. The most cited article was the work by Batson (1169 citations) that was published in 1940 and described the role of the vertebral veins in the spread of metastases. The second most cited article was Patchell's 2005 study (594 citations) discussing decompressive resection of spinal cord metastases. The third most cited article was the 1978 study by Gilbert that evaluated treatment of epidural spinal cord compression due to metastatic tumor (560 citations).

CONCLUSIONS

The field of metastatic spine disease has witnessed numerous milestones and so it is increasingly important to recognize studies that have influenced the field. In this bibliographic study the authors identified and analyzed the most influential articles in the field of metastatic spine disease.

Factors associated with improved survival following surgical treatment for metastatic prostate cancer in the spine: retrospective analysis of 29 patients in a single center

Background

Prostate cancer (PCa) is very common and frequently metastasizes to the spine. However, PCa spinal metastases were rarely reported in the literature. In this study, the outcome of therapies and prognostic factors affecting surgical outcomes for patients with PCa spinal metastases are discussed to select the best candidates for aggressive surgical resection.

Methods

All patients affected by the spinal metastatic PCa surgically treated at our spine tumor center were reviewed. Overall survival was analyzed from the time of spinal surgery. A univariate survival analysis and a multivariate Cox proportional hazard analysis to identify independent prognostic factors were carried out. The survival rate was estimated by the Kaplan-Meier method, and differences were analyzed by the log-rank test. Factors with P values of 0.1 or less were subjected to multivariate analysis for survival rate by multivariate Cox proportional hazard analysis.

Results

A total of 31 consecutive patients were identified. Of these, 29 underwent surgical resection. The median survival time of all patients after their spinal surgery was 44.0 months. Visceral metastases, revised Tokuhashi scores (0–8/9–11/12–15), Tomita scores (7–10/2–6), hormone status, and bisphosphonate treatment were suggested as the potential prognostic factors through univariate analysis. As they were submitted to the multivariate Cox regression model, visceral metastases and Tomita score were found as independent prognostic factors.

Conclusions

Patients without visceral metastases and a Tomita score no more than 6 are favorable prognostic factors for PCa metastases in the mobile spine.

The Tokuhashi score: effectiveness and pitfalls

PURPOSE

Accurate survival estimation is prerequisite to determine the most appropriate treatment for patients with metastatic spine disease. Several authors have proposed classification systems analyzing clinical and radiological parameters, such as, performance status, metastasis localization, and primary tumor histotype, but the modified Tokuhashi score (mTS) is the most widely used. Although it is regarded as one of the most complete and accurate systems, it does not take the effectiveness of new therapeutic strategies into consideration, contributing to a progressive loss of accuracy. The purpose of this review is to verify the ability of the mTS to accurately estimate metastatic spine patient survival, nearly 10 years after it was introduced.

METHODS

A literature review was conducted to evaluate mTS accuracy to predict metastatic spine patient survival.

RESULTS

Ten studies were selected, representing 1686 patients. The total predictive accuracy of the mTS was 63.00%; for patients expected to survive less than 6 months (group I), it was 64.10%; 6-12 months (group II), 55.32%; and more than 12 months (group III), 77.21%. A progressive decrease in accuracy over time was statistically significant in groups I and II.

CONCLUSIONS

The mTS is suggestive of actual survival for patients with a good prognosis. It is less accurate for patients with an estimated survival of less than 12 months. The decreasing trend in mTS accuracy over time will likely further reduce mTS utility. An important opportunity exists to develop new instruments to assist spine surgeons and oncologists to choose appropriate surgical or non-surgical treatment modalities for patients with metastatic spine disease.

Influence of the Preoperative Neurological Status on Survival After the Surgical Treatment of Symptomatic Spinal Metastases With Spinal Cord Compression

STUDY DESIGN

Consecutive case-series.

OBJECTIVE

The main purpose of this study was to analyze the relationship between the preoperative neurological status and subsequent survival of patients undergoing surgical treatment for symptomatic spinal metastases.

SUMMARY OF BACKGROUND DATA

The survival of cancer patients has increased over recent years with improvements in oncologic therapy. As many as 70% of cancer patients develop spinal metastases and ∼10% of all cancer patients are treated for metastatic spinal cord compression.

METHODS

We retrospectively analyzed 166 patients who underwent surgery for symptomatic spinal metastases in our department between 2005 and 2012. The evaluated factors were age, primary tumor aggressiveness (slow, moderate, rapid growing), spinal location (cervical, thoracic, lumbar, and sacral), operation type (posterior decompression, anterior or posterior instrumented procedure, and radical combined instrumented surgery), preoperative evaluation using the revised Tokuhashi scoring system (<9, 9-11, and 12-15), pre- and postoperative neurological status according to the Frankel score (A-C and D-E), and the site of the main spinal cord compression (anterior, posterior, or combined). Postoperative complication and recurrence rate were also monitored.

RESULTS

The mean age of the patients was 62 ± 12 years. The median survival time after surgery was 16.0 months. Preoperative neurological status influenced survival time significantly; the median survival was 5.1 months in Frankel A-C and 28.2 months in Frankel D-E (P < 0.001). Improvement on the Frankel scale did not influence the survival time (P = 0.131). When the patients' age was <65 years this related to a significantly longer survival time (P = 0.046). The Tokuhashi score predicted patient's survival independently (P < 0.001). The other factors had no statistical significance.

CONCLUSION

The most important factors influencing postoperative survival time of these patients with symptomatic spinal metastases was the preoperative neurological condition and the Tokuhashi scoring system, which together represents a useful tool for planning the extent of surgical treatment.

Correlation between actual survival and Tokuhashi and tomita scores in spine metastases

<sec><title>OBJECTIVE:</title><p> To evaluate the accuracy of the scores of Tokuhashi and Tomita and the actual survival of patients with vertebral metastases.</p></sec><sec><title>METHODS:</title><p> A retrospective assessment of 45 patients with spinal metastases. Thirty-one patients underwent surgical treatment and adjuvant therapy and 14 received conservative treatment (chemotherapy/radiotherapy) or palliative/supportive, depending on the scores of Tokuhashi and Tomita.</p></sec><sec><title>RESULTS:</title><p> In the study, 80% of patients were female and the mean age was 57.8 years (SD=11.3 years). The most frequent primary tumors were breast and prostate (68.9%). The accuracy of Tokuhashi scale was 53.4% and the Tomita, 64.5%. The concentration of Tomita range of correct classification was in the category of survival > 12 months (57.8%), while the Tokuhashi scale presented some adjustment in the other categories, < 6 months (15.6%) and 6 to 12 months (2.2%). The histological type of the primary tumor was the only variable that statistically influenced the survival time of patients (p<0.001), and patients with lung or liver tumor (most aggressive) presented a risk of death 9.89 times higher than patients with primary tumors of breast or prostate (less aggressive) (95% CI: 3.10 to 31.57).</p></sec><sec><title>CONCLUSION:</title><p> The Tokuhashi and Tomita scores showed good accuracy with respect to the actual survival of patients with tumor metastasis in the spine.</p></sec>

Tokuhashi score and other prognostic factors in 260 patients with surgery for vertebral metastases

BACKGROUND

Metastatic disease of the spine is an increasingly common public health problem. Surgery should be an integral component of the overall cancer treatment plan and, importantly, must neither delay not jeopardize any of the other components. The prognosis governs the choice of the surgical strategy. Tokuhashi et al. developed a prognostic score in 1990, then revised it in 2000 and 2005. Here, our objective was to evaluate the performance of the Tokuhashi score in a cohort of 260 patients and to look for other variables that might improve preoperative outcome prediction.

MATERIAL AND METHOD

We retrospectively established a single-centre cohort of 260 patients who underwent spinal metastasis surgery between 1998 and 2008. For each patient, the following data were collected prospectively: socio-demographic features, history of the malignancy, variables needed to determine the Tokuhashi score, and treatments used. SAS 9.0 software was chosen for the statistical analysis. Variables were described as mean ± SD, overall survival was estimated using the Kaplan-Meier method, and survivals in subgroups were compared by the log-rank test. To assess agreement between survival predicted by the Tokuhashi score and observed survival, we computed Cohen's kappa and interpreted the results according to Landis and Koch.

RESULTS

There were 143 females and 117 males with a mean age of 59 years and overall median survival of 10 months. Median observed survivals in the three Tokuhashi score categories (< 6, 6-12, and > 12 months predicted survival) were 5, 10, and 36 months, respectively. These survival times differed significantly (P < 0.0001). Cohen's kappa indicated moderate agreement between predicted and observed survivals. Other factors associated with significant survival differences were time from cancer diagnosis to metastasis diagnosis (synchronous, < 2 years, 2-5 years, or > 5 years; P < 0.0001) and age (< 70 years or ≥ 70 years, P = 0.0053).

CONCLUSION

Our cohort study supports the validity and reproducibility of the Tokuhashi score. Our finding that shorter time to metastasis diagnosis and age ≥ 70 years were also significantly associated with survival in our population invites further efforts to improve and update the Tokuhashi score.

Reassessment of scoring systems and prognostic factors for metastatic spinal cord compression

BACKGROUND CONTEXT

The incidence of metastatic spinal cord compression (MSCC) is increasing, paralleling increasing life expectancy of patients. However, management of MSCC and relevance of scoring systems remain controversial.

PURPOSE

The aims of our study were to analyze the feasibility and outcomes of spinal surgery, to identify prognostic factors for survival, and to assess the accuracy of scoring systems in patients with malignancies associated with MSCC.

STUDY DESIGN

Retrospective analysis of all patients with MSCC operated in our institution.

METHODS

Outcomes of surgery, prognostic factors for survival, and relevance of Tomita and Tokuhashi scores were investigated.

RESULTS

One hundred forty-eight patients were included: 66% were hyperalgic (pain score >6) and Frankel score (FS) was decreased in 49%. Seventy-three percent of patients had laminectomy with spinal fixation. After surgery, pain decreased in 75% of cases, FS was improved in 31%, and 92% of patients were ambulatory. Postoperative complication rate was 16%. Median overall survival (OS) was 8.9 months (95% confidence interval, 4.4-13). Only Tokuhashi score was relevant, but predictive accuracy of survival was just 51%. In univariate analyses, hyperalgia (p=.001), primary tumor site, extrabone metastases (p<.001), Karnofsky performance status (KPS) less than 70 (p<.001), poor American Society of Anesthesiologist (ASA) score (p<.001) or FS (p=.01), and absence of postoperative chemotherapy (p<.001) were associated with shorter OS. In multivariate analysis, only extrabone metastases (p=.004), KPS (p=.001), and ASA score (p=.007) remained significantly associated with OS.

CONCLUSIONS

Surgery for MSCC is associated with limited morbidity, improved autonomy, and pain relief. Usual scores do not seem relevant, whereas ASA score, KPS, and extrabone metastases are significantly associated with OS.

Spinal metastases due to thyroid carcinoma: an analysis of 202 patients

BACKGROUND

Spinal metastases (SMs) due to thyroid cancer (TC) are associated with significantly reduced quality of life. The goal of this study is to analyze the clinical manifestations, presentation, and treatments of TC SMs, and to describe specific features of SMs associated with different TC types.

PATIENTS AND METHODS

A retrospective analysis of 202 TC SM patients treated at Medstar Washington Hospital Center (37) and collected from the literature (165) was performed.

RESULTS

The mean age of patients with SMs was 56.9±14.7 years, and the female-to-male ratio was 2.1:1. Of all patients, 29% (28% of follicular thyroid cancer [FTC] and 37% of papillary thyroid cancer [PTC]) had SMs only. Twenty-nine percent of all patients and 54% of patients with single-site SMs had neither bone non-SMs nor solid organ metastases at the time of presentation. Thirty-five percent of patients had SMs as an initial presentation of TC. TC patients presenting with SMs had a lower rate of other bone and visceral involvement compared with patients whose SMs were diagnosed at the time of thyroid surgery or during follow-up (p<0.05). SMs were more often the initial manifestation of FTC (41% vs. 24%), while PTC SMs were more commonly diagnosed after TC diagnosis (76% vs. 59%; p<0.05). PTC SMs were more frequently diagnosed as synchronous (63% vs. 36% in FTC) versus FTC SMs that developed as metachronous metastases (64% vs. 37% in PTC; p<0.01). All FTC SMs developed within 82 (0-372) months and all PTC SMs within 35 (0-144) months (p<0.01). In FTC SMs as TC manifestation, solid organ metastases involvement was less common than in FTC SMs that were found after TC diagnosis (34% vs. 67%; p<0.01); multisite FTC SMs compared to solitary FTC SMs were associated with the development of other bone nonspinal metastases (82% vs. 30%; p<0.01) and solitary organ metastases (65% vs. 41%; p<0.01). These correlations were not observed in PTC SMs. FTC patients often had neural structure compression (myelopathy/radiculopathy; 72% vs. 36% in PTC), while PTC patients frequently were asymptomatic (38% vs. 5% in FTC; p<0.01). FTC SMs more commonly were (131)I-avid (p<0.01). FTC patients required surgery more frequently (72% vs. 55% in PTC; p<0.05).

CONCLUSIONS

Our study reveals that a significant part of TC SMs patients have solitary spinal involvement at the time of presentation and may be considered for aggressive treatment with the intention to improve quality of life and survival. FTC SMs and PTC SMs appear to have distinct presentations, behavior, and treatment modalities, and should be categorized separately for treatment and follow-up planning.

Current treatment modalities for spinal metastases secondary to thyroid carcinoma

BACKGROUND

The spine is the most common site of bone metastases due to thyroid cancer, which develop in more than 3% of patients with well-differentiated thyroid cancer. Nearly half of patients with bone metastases from thyroid cancer develop vertebral metastases. Spinal metastases are associated with significantly reduced quality of life due to pain, neurological deficit, and increased mortality.

SUMMARY

Treatment options for patients with thyroid spinal metastases include radioiodine therapy, pharmacologic therapy, and surgical treatments, with recent advances in radiosurgery and minimally invasive spinal surgery as well. Therapeutic interventions require a multidisciplinary approach and aim to control pain, preserve or improve neurologic function, optimize local tumor control, and improve quality of life. We have proposed a three-tiered approach to the management and practical algorithms for patients with spinal metastases from thyroid carcinoma.

CONCLUSIONS

The introduction of novel and improved techniques for the treatment of spinal metastases has created the opportunity to significantly improve control of metastatic tumor growth and the quality of life for the patients with spinal metastases from thyroid cancer. In order for these options to be effectively used, a multidisciplinary approach must be applied in the management of the patients with thyroid spinal metastases.

Scoring system for prediction of metastatic spine tumor prognosis

Assessing the prognosis before treatment for metastatic spine tumor is extremely important in therapy selection. Therefore, we review some prognostic scoring systems and their outcomes. Articles with combinations of two keywords among “metastatic spine tumor” and “prognosis”, “score”, “scoring system”, “predicting”, or “life expectancy” were searched for in PubMed. As a result, 236 articles were extracted. Those referring to representative scoring systems about predicting the survival of patients with metastatic spine tumors were used. The significance and limits of these scoring systems, and the future perspectives were described. Tokuhashi score, Tomita score, Baur score, Linden score, Rades score, and Katagiri score were introduced. They are all scoring systems prepared by combining factors that affect prognosis. The primary site of cancer and visceral metastasis were common factors in all of these scoring systems. Other factors selected to influence the prognosis varied. They were useful to roughly predict the survival period, such as, “more than one year or not” or “more than six months or not”. In particular, they were utilized for decision-making about operative indications and avoidance of excessive medical treatment. Because the function depended on the survival period in the patients with metastatic spine tumor, it was also utilized in assessing functional prognosis. However, no scoring system had more than 90% consistency between the predicted and actual survival periods. Future perspectives should adopt more oncological viewpoints with adjustment of the process of treatment for metastatic spine tumor.

A Study of the Predictive Value of the Modified Tokuhashi Score in Metastatic Spinal Tumour Causing Cord Compression in a Southern Chinese Population

Introduction

It is generally agreed that operative intervention is beneficial in carefully selected groups of patients with metastatic spinal cord compression (MSCC). Tokuhashi et al have presented a preoperative scoring system to predict patient survival, which is widely used as a guideline for making a decision on whether to operate or not. However, only limited data are available regarding the validity of the Tokuhashi score in Southern Chinese populations.

Materials and methods

We report a series of 128 patients treated in our hospital from 2000 to 2010. All patients were diagnosed to have spinal metastasis of different origins with cord compression. Of the 128, 59 underwent operation and the remaining 69 received conservative treatments. The Tokuhashi score was then calculated retrospectively. The survival rate was analysed and p < 0.05 was considered statistically significant.

Results

In our series, the accuracy of the modified Tokuhashi scoring for predicting the survival rate in patients with MSCC was demonstrated to be 79% (101/128). The poor prognostic group showed statistically significant worse survival than the two better prognostic groups. The type of primary cancer (p = 0.0015), visceral metastasis (p = 0.006), and the general condition (p < 0.001) were confirmed as significant survival prognostic factors. Nasopharyngeal carcinoma (NPC) had the most favourable outcome with a mean survival of 20.1 months.

Conclusion

The modified Tokuhashi score was statistically correlated to the overall survival of MSCC patients in a Southern Chinese population. The type of primary cancer, visceral metastasis, and the general condition were statistically significant survival factors. We recommend weighting a higher score for NPC in the modified Tokuhashi scoring system in view of its favourable prognosis.

Perioperative complication and surgical outcome in patients with spine metastases: retrospective 200-case series in a single institute

OBJECTIVE

Metastatic spinal disease requires a multidisciplinary approach with advanced surgical techniques which improve longevity and the quality of life. The purpose of this study is to compare the surgical outcomes and perioperative complications and mortality among en bloc, debulking, and palliative surgeries in patients with spinal metastasis.

METHODS

From 2005 to 2010, 200 patients who underwent surgical treatment for spinal metastases were enrolled retrospectively. Clinical analysis included primary cancer type, survival following the diagnosis of cancer, postoperative survival, Tokuhashi score, postoperative functional status, postoperative complications and mortality depending on the surgery type. Enrolled patients were divided into 3 groups: en bloc excision, debulking curettage, and palliative surgery. Surgical outcomes including perioperative complication and mortality were compared based on the surgery type.

RESULTS

The mean age was 59.9 years (range 21-87). The major types of primary cancer were lung (42 cases), liver (27 cases), and colorectal cancer (27 cases). 62 surgeries (31.0%) were en bloc excisions, 82 (41.0%) were debulking, and 56 (28.0%) were palliative operations. The mean Tokuhashi score was 9.2±3.3 in the en bloc group, 7.2±3.0 in the debulking group and 8.2±2.6 in the palliative group (p=0.001, ANOVA). Mean postoperative survivals were 17.9±22.1 months in the en bloc group, 7.0±11.7 months in the debulking group and 8.5±10.8 months in the palliative group (p=0.022, ANOVA). There were 8 (12.9%) postoperative complications in the en bloc group, 17 (20.7%) in the debulking group, and 8 (14.3%) in the palliative group (p=0.016, chi-square). Three patients (4.8%) in the en bloc group had multiple complications, as did 5 (6.1%) in the debulking group and 2 (3.6%) in the palliative group (p=0.925, chi-square). Among 21 total perioperative deaths, 6 (28.6%) were in the en bloc group, 10 (47.6%) in the debulking group, and 5 (23.8%) in the palliative group (p=0.618, chi-square).

CONCLUSION

Postoperative complications were most common in the debulking group compared to the en bloc and palliative groups, despite the fact that there were no differences in the improvement of neurologic deficits after surgery. Therefore, selecting the proper surgery based on the patients' symptoms and neurologic status is of great significance in the planning stage of the surgery.

Metastatic spinal cord compression as a result of the unknown primary tumour

PURPOSE

Patients presenting with metastatic spinal cord compression (MSCC) due to an unknown primary tumour (UPT) present an interesting problem with limited literature available to provide guidance on management. Our aim was twofold-first, to analyse all our patients with MSCC due to a UPT pre-operatively, to review their treatment and outcome; second, make comparisons with those patients who presented with MSCC due to a known primary tumour (KPT) during the same period.

METHODS

All data was collected retrospectively from October 2004 to October 2009, then prospectively from October 2009 to October 2012 (8 years). We reviewed all patient records held on the database, including patient demographics, primary tumour, neurological outcome (Frankel grade), complications and survival.

RESULTS

During the 8-year study period, out of the 382 patients who underwent emergency surgery for MSCC, 285 patients were included in whom complete information was available. Of these, 17 patients presented with MSCC due to a UPT (6 %; mean age 61 years, 5 M, 12 F). When compared to those with a known primary, the UPT group trended to a longer duration of symptoms prior to surgery (200 vs. 156 days, p = 0.86). They had a similar neurological outcome (88 % remained the same or improved post-operatively vs. 90 % in KPT group; p = 0.42), similar complication rate (23.5 vs. 33.6 %; p = 0.32) and survival (222 vs. 251 days, p = 0.42). The primary site in the UPT group was confirmed in 10/17 (58.8 %)-all 10 were adenocarcinoma [lung (6) and GI (4)].

DISCUSSION

In our series, the incidence of MSCC due to an unknown primary was 6 %. They had similar overall outcome (neurology post-operatively, complications and survival) to those patients with MSCC from a known primary. Our experience would suggest that we need to treat these patients expeditiously with thorough evaluation and urgent treatment.

Current paradigms for metastatic spinal disease: an evidence-based review

INTRODUCTION

Management of metastatic spine disease is quite complex. Advances in research have allowed surgeons and physicians to better provide chemotherapeutic agents that have proven more efficacious. Additionally, the advancement of surgical techniques and radiosurgical implementation has altered drastically the treatment paradigm for metastatic spinal disease. Nevertheless, the physician-patient relationship, including extensive discussion with the neurosurgeon, medicine team, oncologists, radiation oncologists, and psychologists, are all critical in the evaluation process and in delivering the best possible care to our patients. The future remains bright for continued improvement in the surgical and nonsurgical management of our patients with metastatic spine disease.

METHODS

We include an evidence-based review of decision making strategies when attempting to determine most efficacious treatment options. Surgical treatments discussed include conventional debulking versus en bloc resection, conventional RT, and radiosurgical techniques, and minimally invasive approaches toward treating metastatic spinal disease.

CONCLUSIONS

Surgical oncology is a diverse field in medicine and has undergone a significant paradigm shift over the past few decades. This shift in both medical and surgical management of patients with primarily metastatic tumors has largely been due to the more complete understanding of tumor biology as well as due to advances in surgical approaches and instrumentation. Furthermore, radiation oncology has seen significant advances with stereotactic radiosurgery and intensity-modulated radiation therapy contributing to a decline in surgical treatment of metastatic spinal disease. We analyze the entire spectrum of treating patients with metastatic spinal disease, from methods of diagnosis to the variety of treatment options available in the published literature.

The Oswestry Risk Index: an aid in the treatment of metastatic disease of the spine

The revised Tokuhashi, Tomita and modified Bauer scores are commonly used to make difficult decisions in the management of patients presenting with spinal metastases. A prospective cohort study of 199 consecutive patients presenting with spinal metastases, treated with either surgery and/or radiotherapy, was used to compare the three systems. Cox regression, Nagelkerke's R(2) and Harrell's concordance were used to compare the systems and find their best predictive items. The three systems were equally good in terms of overall prognostic performance. Their most predictive items were used to develop the Oswestry Spinal Risk Index (OSRI), which has a similar concordance, but a larger coefficient of determination than any of these three scores. A bootstrap procedure was used to internally validate this score and determine its prediction optimism. The OSRI is a simple summation of two elements: primary tumour pathology (PTP) and general condition (GC): OSRI = PTP + (2 - GC). This simple score can predict life expectancy accurately in patients presenting with spinal metastases. It will be helpful in making difficult clinical decisions without the delay of extensive investigations.

Is surgery for spine metastasis reasonable in patients older than 60 years?

BACKGROUND

Spinal metastases are common in patients older than 60 years with cancer. Because of the uncertainty of survival and the high incidence of fatal complications, however, chemotherapy and radiotherapy generally have been considered preferable and surgery a treatment of last resort for these patients. Further, the selection criteria indicating surgery and reliable prognostic factors for survival remain controversial.

QUESTIONS/PURPOSES

We therefore assessed surgical complications, postoperative function, and risk factors affecting their overall survival.

METHODS

We retrospectively reviewed 92 patients 60 years or older (range, 60-81 years) who had surgery for spinal metastases. The surgical complications were recorded and a VAS pain score, Frankel grade, and Karnofsky score were obtained. Statistical analyses were performed to identify factors associated with survival. The minimum followup was 6 months (mean, 22 months; range, 6-78 months).

RESULTS

Surgical complications occurred in 21 patients. Pain levels decreased postoperatively in 90% of patients and neurologic function improved in 78%. The Karnofsky status improved in 58 patients giving an improvement rate of 63%. The overall survival rates at 1 year and 3 years were 61% and 35% with a median of 15 months. Primary tumor type and Tokuhashi score independently predicted survival in patients with spinal metastases.

CONCLUSION

Our findings suggest surgery for spinal metastasis can achieve pain relief, neurologic improvement, and restoration of general condition but with a high risk of complications. Primary tumor type and Tokuhashi scoring independently predicted survival in patients with spinal metastases after surgery.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Predicting survival for surgery of metastatic spinal cord compression in prostate cancer: a new score

STUDY DESIGN

We retrospectively analyzed prognostic factors for survival in patients with prostate cancer operated for metastatic spinal cord compression.

OBJECTIVE

The aim was to obtain a clinical score for prediction of survival after surgery.

SUMMARY OF BACKGROUND DATA

Survival prognosis is important when deciding about treatment of patients with metastatic spinal cord compression. The criteria for identifying patients with prostate cancer who may benefit from surgical treatment are unclear.

METHODS

The study comprised 68 consecutive patients with prostate cancer operated for metastatic spinal cord compression at Umeå University Hospital, Sweden. The indication for surgery was neurological deficit; 53 patients had hormone-refractory prostate cancer and 15 patients had previously untreated, hormone-naïve prostate cancer. In 42 patients, posterior decompression was performed and 26 patients were operated with posterior decompression and stabilization.

RESULTS

A new score for prediction of survival was developed on the basis of the results of survival analyses. The score includes hormone status of prostate cancer, Karnofsky performance status, evidence of visceral metastasis, and preoperative serum prostate-specific antigen (PSA). The total scores ranged from 0 to 6. Three prognostic groups were formulated: group A (n = 32) with scores 0-1; group B (n = 23) with scores 2-4, and group C (n = 12) with scores 5-6. The median overall survival was 3 (0.3-20) months in group A, 16 (1.8-59) months in group B, and more than half (7 of 12) of patients were still alive in group C.

CONCLUSION

We present a new prognostic score for predicting survival of patients with prostate cancer after surgery for metastatic spinal cord compression. The score is easy to apply in clinical practice and may be used as additional support when making decision about treatment.