The clinical features and prognostic factors of hepatocellular carcinoma patients with spinal metastasis

The role of radiation therapy in the treatment of spine metastases from hepatocellular carcinoma: a systematic review and meta-analysis

OBJECTIVE

Spine hepatocellular carcinoma (HCC) metastases severely worsen quality of life and prognosis, with the role of radiotherapy being controversial. The authors systematically reviewed the literature on radiotherapy for spine metastatic HCCs.

METHODS

The PubMed, Scopus, Web of Science, and Cochrane databases were searched according to the PRISMA guidelines to include studies of radiotherapy for spine metastatic HCCs. Outcomes, complications, and local control were analyzed with indirect random-effect meta-analyses.

RESULTS

The authors included 12 studies comprising 713 patients. The median time interval from diagnosis of HCC to spine metastases was 12 months (range 0–105 months). Most lesions were thoracic (35.9%) or lumbar (24.7%). Radiotherapy was delivered with conventional external-beam (67.3%) or stereotactic (31.7%) techniques. The median dose was 30.3 Gy (range 12.5–52 Gy) in a median of 5 fractions (range 1–20 fractions). The median biologically effective dose was 44.8 Gy10 (range 14.4–112.5 Gy10). Actuarial rates of postradiotherapy pain relief and radiological response were 87% (95% CI 84%–90%) and 70% (95% CI 65%–75%), respectively. Radiation-related adverse events and vertebral fractures had actuarial rates of 8% (95% CI 5%–11%) and 16% (95% CI 10%–23%), respectively, with fracture rates significantly higher after stereotactic radiotherapy (p = 0.033). Fifty-eight patients (27.6%) had local recurrences after a median of 6.8 months (range 0.1–59 months), with pooled local control rates of 61.6% at 6 months and 40.8% at 12 months, and there were no significant differences based on radiotherapy type (p = 0.068). The median survival was 6 months (range 0.1–62 months), with pooled rates of 52.5% at 6 months and 23.4% at 12 months.

CONCLUSIONS

Radiotherapy in spine metastatic HCCs shows favorable rates of pain relief, radiological responses, and local control. Rates of postradiotherapy vertebral fractures are higher after high-dose stereotactic radiotherapy.

Prognostic scoring system for metastatic spine tumors derived from hepatocellular carcinoma

PURPOSE

The prognosis of hepatocellular carcinoma (HCC) has recently improved, and so clinicians have greater opportunity to treat HCC-derived spinal metastases. Therefore, predicting life expectancy is important for determining the optimal treatment strategy for such tumors. This study aimed to investigate the prognostic factors for HCC-derived metastatic spine tumors and to develop a scoring system for predicting life expectancy in such cases.

METHODS

The posttreatment survival time and factors that might influence it were investigated in 62 patients with HCC-derived metastatic spine tumors who were treated at our department (surgery: 27 patients and conservative treatment: 35 patients), and a prognostic scoring system for predicting life expectancy was developed by combining the factors that significantly influenced survival.

RESULTS

In the univariate analyses, sex, the patient's general condition, the presence/absence of major internal organ metastasis, the total revised Tokuhashi score, the serum albumin level, Child-Pugh class, spinal surgery, and bone-modifying agent (BMA) treatment were found to influence the posttreatment survival time. These factors were subjected to multivariate analysis, and a novel scoring system for predicting life expectancy based on the patient's general condition, the serum albumin level (or Child-Pugh class), and BMA treatment was developed. In the retrospective analysis, the concordance rate between the patients' life expectancy and actual survival times was 90.3%.

CONCLUSION

The patient's general condition, the serum albumin level (or Child-Pugh class), and BMA treatment influenced the posttreatment survival times of patients with HCC-derived metastatic spine tumors. A prognostic scoring system based on these factors was proposed.

Natural disease progression and novel survival prediction model for hepatocellular carcinoma with spinal metastases: a 10-year single-center study

BACKGROUND

Individual prediction of life expectancy in patients with spinal metastases from hepatocellular carcinoma (HCC) is key for optimal treatment selection, especially when identifying potential candidates for surgery. Most reported prognostic tools provide categorical predictions, and only a few include HCC-related factors. This study aimed to investigate the natural progression of the disease and develop a prognostic tool that is capable of providing individualized predictions.

METHODS

Patients with HCC-derived metastatic spinal disease were identified from a retrospective cohort of patients with spinal metastases who were diagnosed at Chiang Mai University Hospital between 2006 and 2015. Kaplain-Meier methods and log-rank tests were used to statistically evaluate potential factors. Significant predictors from the univariable analysis were included in the flexible parametric survival regression for the development of a prognostic prediction model.

RESULTS

Of the 1143 patients diagnosed with HCC, 69 (6%) had spinal metastases. The median survival time of patients with HCC after spinal metastases was 79 days. In the multivariable analysis, a total of 11 potential clinical predictors were included. After backward elimination, four final predictors remained: patients aged > 60 years, Karnofsky Performance Status, total bilirubin level, and multifocality of HCC. The model showed an acceptable discrimination at C-statistics 0.73 (95% confidence interval 0.68-0.79) and fair calibration.

CONCLUSION

Four clinical parameters were used in the development of the individual survival prediction model for patients with HCC-derived spinal metastases of Chiang Mai University or HCC-SM CMU model. Prospective external validation studies in a larger population are required prior to the clinical implication of the model.

Prognostic factors in hepatocellular carcinoma patients with bone metastases

Purpose

To identify the prognostic factors that could influence survival and to compare prognoses of the patients with the number of the risk factors that might assist in the adequate management of hepatocellular carcinoma (HCC) patients with bone metastases that showed a heterogeneous range of survival.

Materials and Methods

A total of 41 patients, treated with radiotherapy (RT) for bone metastases from HCC from 2014 to 2017, were enrolled retrospectively. Survival was determined by the Kaplan–Meier method from the start of the RT for metastatic bone lesions. Pre-RT clinical features were evaluated and their influences on survival were analyzed. The significant factors were considered to compare survivals according to the number of prognostic factors.

Results

Median follow-up was 6.0 months (range, 0.5 to 47.0 months). The median overall survival was 6.5 months, and the 1-year and 2-year survival rates were 35.5% and 13.5%, respectively. Multivariate analysis revealed that the Child-Pugh class A group, alpha-fetoprotein increased more than 30 ng/mL, and HCC size of more than 5 cm were associated with worse overall survival. The median survivals in HCC with none, 1, 2, and 3 of the aforementioned risk factors were 19.5, 9.0, 2.5, and 1.0 months, respectively (p < 0.05).

Conclusion

Our results show that the overall survivals were significantly different according to the number of the risk factors among HCC patients with bone metastases who showed various lengths of survival.

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.

Establishment of a Disease-Specific Graded Prognostic Assessment for Hepatocellular Carcinoma Patients with Spinal Metastasis

Background/Aims

Hepatocellular carcinoma (HCC) patients with spinal metastasis (SM) show heterogeneous lengths of survival. In this study, we develop and propose a graded prognostic assessment for HCC patients with SM (HCC-SM GPA).

Methods

We previously reported the outcomes of 192 HCC patients with SM who received radiotherapy from April 1992 to February 2012. Prognostic factors that significantly affected survival in that study were used to establish the HCC-SM GPA. Validation was performed using an independent cohort of 63 patients recruited from September 2011 to March 2016.

Results

We developed the HCC-SM GPA using the following factors: Eastern Cooperative Oncology Group performance status (0–2, 0 point; 3–4, 1 point), controlled primary HCC (yes, 0 point; no, 2 points), and extrahepatic metastases other than bone (no, 0 point; yes, 1 point). Patients were stratified into low (GPA=0), intermediate (GPA=1 to 2), and high risk (GPA=3 to 4). When applied to the validation cohort, the HCC-SM GPA determined median survival durations of 13.6, 4.8, and 2.6 months and 1-year overall survival rates of 58.3%, 17.8%, and 7.3% for the low-, intermediate-, and high-risk patient groups, respectively (p<0.001).

Conclusions

Our newly proposed HCC-SM GPA successfully predicted survival outcomes.

Treatment outcomes of patients with spinal metastases derived from hepatocellular carcinoma

BACKGROUND

The prognosis of hepatocellular carcinoma (HCC) used to be poor, but it has recently improved, which has meant that clinicians have greater opportunity to treat spinal metastases and the associated epidural spinal cord compression. However, there have been few systematic functional studies about HCC-derived spinal metastases. The treatment outcomes of surgical treatment for HCC-derived metastatic spinal tumors were investigated.

METHODS

The post-treatment survival period and pain, paralysis, and disturbance of activities of daily living (ADL) were investigated in 60 patients (surgery 25, conservative treatment 35).

RESULTS

The mean post-treatment survival period was 7.4 ± 8.2 months (range 0.3-36 months). Univariate analysis indicated that the following factors influenced survival: the patient's general condition, presence/absence of major internal organ metastasis, serum albumin level, Child-Pugh classification, surgical treatment for spinal metastasis, and bone-modifying agent treatment. In the multivariate analysis of these 6 items, 3 significant factors were extracted: the patient's general condition, the serum albumin level, and bone-modifying agent treatment. Pain significantly improved in both groups (p < 0.001). Paralysis did not change significantly in the surgical group (p = 0.575), but it was significantly aggravated in the conservative treatment group (p = 0.047). The ADL abilities of the surgical group improved significantly (p < 0.001).

CONCLUSION

Most patients exhibited poor survival. In the conservative treatment group, paralysis was significantly aggravated, and little improvement was seen in the patients' ADL abilities. In the surgical group, the patients' ADL abilities improved significantly, but their paralysis did not. Therefore, surgery should be actively performed for HCC-derived spinal metastasis whenever it is indicated.

Stereotactic ablative body radiotherapy for spinal metastasis from hepatocellular carcinoma: its oncologic outcomes and risk of vertebral compression fracture

Spinal metastases from hepatocellular carcinoma (HCC) require high-dose irradiation for durable pain and tumor control. Stereotactic ablative body radiotherapy (SABR) enables the delivery of high-dose radiation. However, but vertebral compression fracture (VCF) can be problematic. The aim of his study is to evaluate the outcome and risk of VCF after SABR for spinal metastasis from HCC. We retrospectively reviewed 33 lesions in 42 spinal segments from 29 patients who received SABR with 1 fraction (16-20 Gy), or 3 fractions (18-45 Gy) from September 2009 to January 2015. The 1-year local control (LC) rate was 68.3%. Radiographic grade of cord compression (RGCC) was the only independent prognostic factor associated with LC (P = 0.007). The 1-year ultimate LC rate including the outcome of salvage re-irradiation was 87.2%. The pain response rate was 73.3% according to the categories of the International Bone Metastases Consensus Group. The 1-year VCF-free rate was 71.5%. Pre-existing VCF (P < 0.001) and only-lytic change (P = 0.017) were associated with a higher post-SABR VCF rate. One-third of post-SABR VCFs required interventions. SABR for spinal metastases from HCC provided efficacious LC, especially for lesions with RGCC ≤ II, and showed effective and durable pain relief. As VCF after SABR occurred frequently for vertebral segments with pre-existing VCF and only-lytic change, early preventive vertebroplasty is considerable for those high-risk vertebral segments.

An unusual initial presentation of hepatocellular carcinoma as a sellar mass

Sellar masses are frequently adenomatous pituitary tumors. Metastatic disease is unusual, often mimicking the presentations of adenomas. Hepatocellular carcinoma (HCC) is the most common primary hepatic malignancy but unusual to have a pituitary metastasis (PM). A 65-year-old man presented with headache, diplopia, ptosis, decreased vision in the right eye and unintentional weight loss of 32lbs. Preliminary out-patient work-up revealed a mass in the pituitary region. Cranial imaging showed 3.1 cm × 3.2 cm × 4.4 cm lesion. Abdominal imaging (computed tomography and magnetic resonance imaging) demonstrated a lobulated, nodular and heterogeneous right lobe of the liver. Trans-sphenoidal resection of the sellar mass favored metastatic HCC on histology. Liver biopsy confirmed HCC. We recommend maintaining an increased clinical suspicion upon evaluation of nonclassical clinical and radiological presentations of suspected PM/malignancy; as well as pursuing additional investigations in all early cases.

Successful Total En Bloc Spondylectomy of T7 Vertebra for Hepatocellular Carcinoma Metastasis After Living Donor Liver Transplantation

STUDY DESIGN

Case report.

OBJECTIVE

We report a patient who was successfully treated with total en bloc spondylectomy (TES) for T7 metastasis after living donor liver transplantation for hepatocellular carcinoma (HCC).

SUMMARY OF BACKGROUND DATA

Spinal metastasis from HCC has a poor prognosis. There are only a few studies on surgical outcomes of spinal metastasis from HCC. Because of the high surgical morbidity and short life expectancy in patients with HCC with spinal metastasis, TES is not considered in these patients, although several studies have reported satisfactory results for TES for some types of metastatic spinal tumors. Liver transplantation (LT) is the curative treatment option for early HCC. However, the recurrence of HCC is a possible problem after LT, although no reports on surgery for spinal metastasis following LT for HCC have been published. We report on the first case of a patient who was successfully treated with TES for T7 metastasis after living donor LT for HCC.

METHODS

The patient was a 65-year-old man, who had undergone living donor LT for HCC 2 years before. His main symptom was progressive gait disturbance because of the spinal cord compression by the tumor at T7. Radiology and pathology examinations revealed a solitary metastasis at T7 with neither recurrence in the liver nor metastasis in the other organs. We performed TES using a pedicle screw system and a mesh cage filled with frozen autografts.

RESULTS

After surgery, the patient showed clear improvement in neurological symptoms. At 3 months after surgery, a T4 metastasis was detected with magnetic resonance imaging, and the patient was treated with heavy ion radiotherapy. He could walk without a cane and there was no evidence of recurrence at 1.5 years after surgery.

CONCLUSIONS

Solitary spinal metastasis of HCC may become an indication for TES if liver function improves after LT.

LEVEL OF EVIDENCE

5.

Outcomes after surgery for spinal metastasis of colorectal origin: case series

Study Design

Retrospective study.

Purpose

The aim of this study was to evaluate the clinical management and outcomes of patients who underwent surgical intervention for metastatic colorectal adenocarcinoma of the spine.

Overview of Literature

Gastrointestinal (GI) cancer metastasis to the spine are relatively rare and represent later manifestations of the disease. Studies and reports on the outcomes of patients who undergo surgery for spinal metastasis of GI origin are scarce.

Methods

A retrospective chart review of all patients who underwent surgery for spinal metastasis of colorectal origin was performed. Four patients were identified. Patient characteristics, outcomes, and survival were analyzed.

Results

Two patients experienced improvement in pain or myelopathic symptoms. Although the mean survival was 15.3 months, this average included a patient still living at 57.1 months. The mean survival was just 1.3 months for the 3 patients who expired.

Conclusions

In certain cases, symptomatic improvement with prolonged survival is possible after surgery for metastatic spinal lesions of colorectal origin; however, survival is poor in the majority of cases.

Dose escalation using helical tomotherapy improves local control in spine metastases from primary hepatic malignancies

BACKGROUND & AIMS

This study was designed to reveal the prognostic significance of dose-escalated radiotherapy with tomotherapy in local control for spine metastases of primary hepatic tumours.

METHODS

From April 2006 to May 2012, 23 hepatocellular carcinoma patients and 7 intrahepatic cholangiocellular carcinoma patients (total 30 patients, 42 spinal lesions) were treated for metastatic spine lesions with helical tomotherapy (HT). The gross tumour volume (GTV) was defined as a tumour evident from computed tomography and magnetic resonance imaging. Median values were as follows: GTV total dose of 48 Gy (range 21-51), fraction size of 6 Gy (range 3-8) and eight fractions (range 3-17). Pain response was checked according to visual analogue scale (from 0 to 10).

RESULTS

The median follow-up was 5.6 months. Six events of local failure occurred, including five lesions in which spinal canals were involved at radiotherapy. Local control rate at 3 months was 86.6%. Biological equivalent dose (BED) was correlated with local control (AUC = 0.833). Higher BED (>56.0 Gy10 ) was associated with increased local control (P = 0.004). The median time to local progression in patients receiving ≤56.0 Gy10 and >56.0 Gy10 were 3 and 20.8 months respectively. Dose escalation (BED > 56.0 Gy10 ) was also associated with improved progression-free survival (median 14.7 vs. 2.8 months, P = 0.010). Pain reduction was observed in 90.9% (20/22) of patients with painful bone metastases.

CONCLUSIONS

Dose-escalated radiotherapy (BED > 56.0 Gy10 ) using HT improved local control in spinal metastases of hepatic malignancies.

Surgical outcome of spinal hepatocellular carcinoma metastases

BACKGROUND

Spinal hepatocellular carcinoma (HCC) metastases are increasing with improved survival of patients with HCC. However, its treatment outcome, particularly regarding functional outcome, has not been adequately investigated.

OBJECTIVE

To present the surgical outcome of spinal HCC metastases and demonstrate prognostic factors for survival and ambulation time.

METHODS

Thirty-three patients (30 males, 3 females) were retrospectively reviewed. Child-Pugh classification was used to assess hepatic function. Preoperatively, 19 patients could ambulate (group A) and 14 patients could not (group B). Preoperatively, 18 patients received conventional fractionated radiotherapy.

RESULTS

The spinal metastases were removed to achieve sufficient neural decompression. If destabilization developed, instrumentation and/or vertebroplasty were performed. Postoperatively, conventional radiotherapy was administered to 13 patients. Patients survived for 203 ± 31 days. Child-Pugh classification and preoperative/postoperative ambulatory ability were correlated with survival time, with Child-Pugh classification being the most significant factor (hazard ratio, 3.75; 95% confidence interval: 1.38-10.22). After the operation, ambulatory ability was maintained in all group A patients and was recovered in 4 in group B. Twenty-three patients could ambulate for 285 ± 62 days. Preoperative ambulatory status and Child-Pugh classification were correlated with a longer ambulatory period, with preoperative ambulatory status most significant (hazard ratio, 8.62; 95% confidence interval: 2.39-31.04). Patients died 81 ± 71 days after the loss of ambulatory ability, regardless of postoperative ambulatory status.

CONCLUSION

In spinal HCC metastasis, ambulatory status and hepatic function were significantly correlated with survival and ambulation time. Both ambulatory status and hepatic function should be considered in the selection of surgical candidates.

Resumption of ambulatory status after surgery for nonambulatory patients with epidural spinal metastasis

BACKGROUND CONTEXT

Improving the surgical outcome of nonambulatory patients with metastatic epidural spinal compression has been of great interest lately. Although there have been many reports regarding the surgical outcome of spinal metastasis, the surgical outcome in terms of the probability of operative success for nonambulatory patients has not been thoroughly described. If the probability of ambulatory recovery is known, the optimal surgical indications can be determined and implemented.

PURPOSE

To predict the surgical outcome and probability of ambulatory resumption for nonambulatory patients with spinal metastasis.

STUDY DESIGN

Retrospective analysis.

PATIENT SAMPLE

The surgical outcomes of patients who could not ambulate independently because of spinal metastasis from 1987 to 2010 were analyzed.

OUTCOME MEASURES

The primary end point was postoperative ambulatory status. The secondary end point was survival time.

METHODS

Fifty-seven patients who could not ambulate independently at the time of surgery were included in the study. We defined "independent ambulation" as a better functional status than Nurick Grade 3, which is defined as "difficulty in walking which was not so severe as to require someone's help to walk." Preoperatively, functional status was Nurick Grade 4 in 21 patients and Grade 5 in 36 patients. Weakness developed 10.5 ± 11.9 days (median, 7.0; range, 1-80) before the operation and steadily worsened. Patients were unable to walk starting from 3.6 ± 4.9 days (median, 1.8; range, 0.5-23) before the operation. The spinal metastases were circumferentially decompressed.

RESULTS

Postoperatively, 39 patients (68%) could walk. Complications occurred in 26% (15/57) of the patients, and the major complication rate was 12% (7/57). The mortality rate was 5% (3/57). The patient survival time was 287 ± 51 days (median, 128) after the operation. Postoperative ambulatory status (yes vs. no, p < .01) and occurrence of major complication (yes vs. no, p < .01) affected survival time. Overall, patients could walk for 193±41 days (median, 114) postoperatively. Motor grade (grade ≥ 4/5 vs. <4/5, p < .01) and the occurrence of a major complication (yes vs. no, p < .01) were significant factors for resumption of ambulation. The rate of ambulation resumption was 95% (20/21) in patients with a motor grade of 4 of 5, whereas it was 53% (19/36) in patients with a motor grade less than 4 of 5 (p < .01).

CONCLUSIONS

The survival time of nonambulatory patients was dependent on ambulation recovery. About 95% of the nonambulatory patients could walk after surgery, when the operation was done in a timely manner with good remaining motor function. However, given the short life expectancy and the considerable surgical complication rate, surgery should only be prudently recommended to patients with optimal indications.

Central nervous system involvement in hepatocellular carcinoma: clinical characteristics and comparison of intracranial and spinal metastatic groups

From January 1993 to December 2006 we analyzed the clinical characteristics of patients with hepatocellular carcinoma (HCC) with central nervous system (CNS) metastasis at the Kaohsiung Chang Gung Memorial Hospital, Taiwan. Forty-six patients with HCC and CNS metastasis were identified, of whom 36 had intracranial metastasis and 10 had spinal metastasis. The clinical presentations, laboratory data and imaging studies were collected and analyzed. The age at the time of HCC diagnosis ranged from 34 to 78 years; CNS metastasis occurred between 0 and 85 months after diagnosis and death followed between 0 and 93 months later. The Glasgow Coma Scale (GCS) score at the time of CNS metastasis ranged from 7 to 15 and the Child-Pugh score at diagnosis of HCC ranged from 5 to 15. Patients with spinal metastasis had a higher GCS score and lower Child-Pugh score at diagnosis. None of the serum biochemical studies showed unique abnormalities. From the data currently available, intracranial metastasis is the most common site of CNS metastasis of HCC. Advances in treating and diagnosing HCC have improved patient outcomes remarkably; however, CNS metastasis continues to have a grave prognosis. Without a specific biomarker for predicting CNS involvement in HCC, a high index of suspicion for the diagnosis should be maintained, particularly in HCC hyperendemic areas such as Taiwan.

Preoperative scoring systems and prognostic factors for patients with spinal metastases from hepatocellular carcinoma

STUDY DESIGN

A retrospective study had been conducted to compare the existing preoperative scoring systems and to find useful prognostic factors for patients with spinal metastases from hepatocellular carcinoma (HCC).

OBJECTIVE

To evaluate different preoperative scoring systems and prognostic factors for patients with spinal metastases from HCC.

SUMMARY OF BACKGROUND DATA

Different scoring systems for metastatic spinal tumor have been designed for prognostic evaluation. However, these scoring systems were formulated from many different types of tumors, so that their efficacy for a certain type of cancer needs to be validated. Furthermore, some serologic test results may enhance the accuracy of the scoring system.

METHODS

We conducted a retrospective study to evaluate 4 prognostic scoring systems and factors in a series of 41 cases with spinal metastases from HCC in a single center. These scoring systems include Tokuhashi revised score, Tomita score, Bauer score, and a revised van der Linden score by the authors. Serologic test items including serum albumin, aspartate aminotransferase, alanine transaminase, and lactate dehydrogenase (LDH) were also evaluated.

RESULTS

The revised Tokuhashi scoring system provided statistically significant differences in survival time between different groups (P = 0.012), while the Tomita and Bauer systems did not show statistically significant differences (P = 0.918 and P = 0.754, respectively). Significantly improved survival was found in patients with good performance status and no visceral metastases (Group C, P = 0.008) in revised van der Linden scores. Univariate and multivariate analyses showed serum albumin and LDH were independent prognostic factors for survival time.

CONCLUSION

Revised Tokuhashi scoring system is practicable and highly predictive, while serum albumin and LDH also have prognostic value in patients with spinal metastases from HCC, especially those without visceral metastases. More accurate prognosis may be obtained if the scoring systems include clinical and laboratory data in future.

Prognosis of operative treatment for metastatic hepatocellular carcinoma of the spine

Developing and developed countries have been reported increasing numbers of hepatocellular carcinoma and increased rates of distant metastasis from hepatocellular carcinoma. Data regarding operative treatments and prognoses of hepatocellular carcinoma metastasis to the spine are lacking in the literature. We retrospectively reviewed 12 patients with hepatocellular carcinoma and metastasis to the spine who had spinal surgery between 1986 and 1996. All 12 patients had severe back pain preoperatively. Posterior surgery alone was performed on two patients, anterior surgery alone in six patients, and combined anterior and posterior surgery in four. Ten of the 12 patients experienced pain relief and their neurologic status was preserved or improved. We designed a new outcome assessment, a modified Prolo scale, to evaluate surgical outcome. Seven of the 12 patients had good or excellent results. Our sample size was limited and we could draw no definite conclusions regarding the prognoses of these patients or the value of surgical intervention; however, we think that operative treatment for spinal metastatic hepatocellular carcinoma lesions may improve quality of life, regardless whether the survival time is prolonged.

LEVEL OF EVIDENCE

Therapeutic study, Level IV (case series--no, or historical, control group). See the Guidelines for Authors for a complete description of levels of evidence.

Hepatocellular carcinoma metastasis in the pituitary gland: case report and review of the literature

Symptomatic pituitary metastases are uncommon and have been reported mainly in autopsy series. Although all types of malignancies can metastasize to the pituitary gland, a review of the literature has indicated that lung and breast carcinomas are the most frequent primary tumors while hepatocellular carcinoma metastasis has only recently been described. A 59-year-old man with abdominal pain and fever was admitted to our hospital. Hepatosplenomegaly was present without signs of ascites. Laboratory tests showed only abnormal hepatic biochemistry while the radiological studies revealed a solid mass occupying the left hepatic lobe. The patient underwent excision of the left hepatic lobe and was closely followed-up. Six months later he readmitted with headache and visual disturbances. MRI revealed a solid mass in the sella region pressing the optic chiasma. Transsphenoidal excision of the pituitary mass was followed and the histological examination of the tumor was compatible with hepatocellular carcinoma. Symptomatic pituitary metastases are uncommon and may be difficult to differentiate from pituitary adenomas. The present case emphasizes on the capricious nature of hepatocellular carcinoma and on the importance of the individualized therapeutic approach.