Prognostic relevance of clinical symptoms in patients with spinal metastases

Survival outcomes and prognostic factors of breast cancer spinal metastases: a retrospective study

PURPOSE

To investigate survival-related factors in patients with breast cancer spinal metastases (BCSM) within the context of multidisciplinary treatment.

METHODS

A retrospective cohort of 78 cases from July 2010 to December 2021 was recruited. These patients underwent surgery-based multidisciplinary treatment. Collected data included demographics, pathologies, symptoms, surgery-related data, adjuvant therapies, postoperative events, and survival data. The primary outcome was overall survival (OS). Kaplan-Meier survival curves were plotted. Univariate analysis employed the log-rank test, and post-hoc multivariate analysis utilized the Cox regression model.

RESULTS

The mean age was 50.9 years. 72 cases (92.3%) reported locoregional pain, and 30 cases (38.5%) presented with neurological dysfunction. The primary pathological subtype was invasive ductal carcinoma (83.3%).

SURGICAL PROCEDURES

total en-bloc spondylectomy (6.4%), debulking surgery (61.5%), palliative surgery (32.1%). Postoperatively, both pain and neurological function significantly improved (P < 0.05). Radiotherapy, endocrine therapy, chemotherapy/targeted therapy were given to 56.4%, 60.3%, 61.5% patients, respectively. The estimated OS was 50.0 months. Tomita's scores (P = 0.355) and Tokuhashi's scores (P = 0.461) showed no significant OS association. Univariate analysis indicated that preoperative neurological dysfunction (P = 0.003), postoperative neurological dysfunction (P = 0.051), adjuvant endocrine therapy (P = 0.025), and hormone receptor expression status (P = 0.009) were associated with patient survival. Multivariate analysis identified endocrine therapy as an independent protective factor for prognosis (aHR = 0.070, 95% CI 0.007-0.727, P = 0.026).

CONCLUSIONS

Patients with BCSM have experienced prolonged survival. Neurological status, adjuvant anti-drugs, and expression of hormone receptors played crucial roles in predicting survival. Conventional prognostic systems may require modification to incorporate these factors. However, this study has limitations inherent to its retrospective design, single-center cohort, and relatively small sample size, which may affect generalizability.

Evaluation of early-death predictive factors and assessment of the benefits-risks ratio among patients with vertebral metastases needing surgery

INTRODUCTION

Preoperative survival prognostication is the main factor to consider when selecting patients who will benefit from metastatic spine surgery. Since patients' selection for surgery is not fully standardized, we aim to identify clinical, oncological and biological markers associated with poor post-operative prognosis.

METHODS

A retrospective analysis was conducted in 105 patients referred to a specialized center for surgery of spinal metastasis between October 2020 and January 2022. Detailed clinical and biological variables were collected. Univariate and multivariate analyses were performed to assess overall survival.

RESULTS

Among the 105 patients included, One-third died within six months. Multivariate survival analysis identified age, Karnofsky score, hyperalgesia and C-reactive protein (CRP) as independently associated with shorter survival. Patients with CRP values above 100 mg/L had a 57% mortality rate at three months. Hyperalgesic patients had a higher mortality rate at three months (p = 0.047), and preoperative use of strong opioids was significantly associated with lower rates of pain relief (p = 0.042). However, pre-operative neurological deficits did not significantly impact survival prognosis (p = 0.92) and were fully corrected by surgery in half of the cases.

CONCLUSION

Incorporating biological markers of inflammation, particularly CRP levels above 100 mg/L, into pre-operative multidisciplinary discussions could improve patient selection for surgery. Hyperalgesic presentation should weigh against surgery, unlike incomplete neurological deficits. This study pointed new clinical and biological markers for short term post-operative survival. Further studies are needed to develop accurate prognosis models to help clinical decision-making.

Synchronous versus metachronous spinal metastasis: a comparative study of survival outcomes following neurosurgical treatment

PURPOSE

Patients with spinal metastases (SM) from solid neoplasms typically exhibit progression to an advanced cancer stage. Such metastases can either develop concurrently with an existing cancer diagnosis (termed metachronous SM) or emerge as the initial indication of an undiagnosed malignancy (referred to as synchronous SM). The present study investigates the prognostic implications of synchronous compared to metachronous SM following surgical resection.

METHODS

From 2015 to 2020, a total of 211 individuals underwent surgical intervention for SM at our neuro-oncology facility. We conducted a survival analysis starting from the date of the neurosurgical procedure, comparing those diagnosed with synchronous SM against those with metachronous SM.

RESULTS

The predominant primary tumor types included lung cancer (23%), prostate cancer (21%), and breast cancer (11.3%). Of the participants, 97 (46%) had synchronous SM, while 114 (54%) had metachronous SM. The median overall survival post-surgery for those with synchronous SM was 13.5 months (95% confidence interval (CI) 6.1-15.8) compared to 13 months (95% CI 7.7-14.2) for those with metachronous SM (p = 0.74).

CONCLUSIONS

Our findings suggest that the timing of SM diagnosis (synchronous versus metachronous) does not significantly affect survival outcomes following neurosurgical treatment for SM. These results support the consideration of neurosurgical procedures regardless of the temporal pattern of SM manifestation.

Postoperative prolonged mechanical ventilation correlates to poor survival in patients with surgically treated spinal metastasis

Objective

Patients with spinal metastasis (SM) are at advanced stages of systemic cancer disease. Surgical therapy for SM is a common treatment modality enabling histopathological diagnosis and the prevention of severe neurological deficits. However, surgery for SM in this vulnerable patient cohort may require prolonged postoperative intensive care treatment, which could adversely affect the anticipated benefit of the surgery. We therefore assessed postoperative prolonged mechanical ventilation (PMV) as an indicator for intensive care treatment with regard to potential correlations with early postoperative mortality and overall survival (OS).

Methods

Between 2015 and 2019, 198 patients were surgically treated for SM at the author´s neurosurgical department. PMV was defined as postoperative mechanical ventilation of more than 24 hours. A multivariate analysis was performed to identify pre- and perioperative collectable predictors for 30 days mortality.

Results

Twenty out of 198 patients (10%) with SM suffered from postoperative PMV. Patients with PMV exhibited a median OS rate of 1 month compared to 12 months for patients without PMV (p < 0.0001). The 30 days mortality was 70% and after one year 100%. The multivariate analysis identified “PMV > 24 hrs” (p < 0.001, OR 0.3, 95% CI 0.02-0.4) as the only significant and independent predictor for 30 days mortality (Nagelkerke’s R2 0.38).

Conclusions

Our data indicate postoperative PMV to significantly correlate to high early postoperative mortality rates as well as to poor OS in patients with surgically treated SM. These findings might encourage the initiation of further multicenter studies to comprehensively investigate PMV as a so far underestimated negative prognostic factor in the course of surgical treatment for SM.

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.

Predictors of Mortality in Patients with Advanced Cancer-A Systematic Review and Meta-Analysis

To timely initiate advance care planning in patients with advanced cancer, physicians should identify patients with limited life expectancy. We aimed to identify predictors of mortality. To identify the relevant literature, we searched Embase, MEDLINE, Cochrane Central, Web of Science, and PubMed databases between January 2000-April 2020. Identified studies were assessed on risk-of-bias with a modified QUIPS tool. The main outcomes were predictors and prediction models of mortality within a period of 3-24 months. We included predictors that were studied in ≥2 cancer types in a meta-analysis using a fixed or random-effects model and summarized the discriminative ability of models. We included 68 studies (ranging from 42 to 66,112 patients), of which 24 were low risk-of-bias, and 39 were included in the meta-analysis. Using a fixed-effects model, the predictors of mortality were: the surprise question, performance status, cognitive impairment, (sub)cutaneous metastases, body mass index, comorbidity, serum albumin, and hemoglobin. Using a random-effects model, predictors were: disease stage IV (hazard ratio [HR] 7.58; 95% confidence interval [CI] 4.00-14.36), lung cancer (HR 2.51; 95% CI 1.24-5.06), ECOG performance status 1+ (HR 2.03; 95% CI 1.44-2.86) and 2+ (HR 4.06; 95% CI 2.36-6.98), age (HR 1.20; 95% CI 1.05-1.38), male sex (HR 1.24; 95% CI 1.14-1.36), and Charlson comorbidity score 3+ (HR 1.60; 95% CI 1.11-2.32). Thirteen studies reported on prediction models consisting of different sets of predictors with mostly moderate discriminative ability. To conclude, we identified reasonably accurate non-tumor specific predictors of mortality. Those predictors could guide in developing a more accurate prediction model and in selecting patients for advance care planning.

Prognostic Factors Associated With Surviving Less Than 3 Months vs Greater Than 3 Years Specific to Spine Stereotactic Body Radiotherapy and Late Adverse Events

BACKGROUND

Patient selection is critical for spine stereotactic body radiotherapy (SBRT) given potential for serious adverse effects and the associated costs.

OBJECTIVE

To identify prognostic factors associated with dying within 3 mo, or living greater than 3 yr, following spine SBRT, to better inform patient selection.

METHODS

Patients living ≤3 mo after spine SBRT and >3 yr after spine SBRT were identified, and multivariable regression analyses were performed. We report serious late toxicities observed, including vertebral compression fractures (VCF) and plexopathy.

RESULTS

A total of 605 patients (1406 spine segments) were treated from 2009 to 2018. A total of 51 patients (8.4%) lived ≤3 mo, and 79 patients (13%) survived >3 yr. Significant differences in baseline features were observed. On multivariable analysis, nonbreast/prostate primaries (odds ratio [ORs]: 28.8-104.2, P = .0004), eastern cooperative oncology group (ECOG) ≥2 (OR: 23.7, 95% CI: 3.2-177, P = .0020), polymetastatic disease (OR: 6.715, 95% CI: 1.89-23.85, P = .0032), painful lesions (OR: 3.833-8.898, P = .0118), and paraspinal disease (OR: 2.874, 95% CI: 1.118-7.393, P = .0288) were prognostic for ≤3 mo survival. The 3- and 5-yr rates of VCF were 10.4% and 14.4%, respectively, and 3- and 5-yr rates of plexopathy were 2.2% and 5.1%, respectively. A single duodenal perforation was observed, and there was no radiation myelopathy events.

CONCLUSION

Shorter survival after spine SBRT was seen in patients with less radiosensitive histologies (ie, not breast or prostate), ECOG ≥2, and polymetastatic disease. Pain and paraspinal disease were also associated with poor survival. Fractionated spine SBRT confers a low risk of late serious adverse events.

Posterior Decompression Surgery and Radiofrequency Ablation Followed by Vertebroplasty in Spinal Metastases from Lung Cancer

Background

Spinal metastases can cause metastatic epidural spinal cord compression (MESCC), which can result in neurological dysfunction and impaired quality of life. This study investigated the safety and effectiveness of posterior decompression surgery and radiofrequency ablation followed by vertebroplasty in spinal metastasis from lung cancer.

Material/Methods

From June 2008 to September 2015, a retrospective analysis was conducted in 15 patients with spinal metastasis from lung cancer. All cases suffered MESCC and underwent posterior decompression surgery to relieve the compression of spinal cord, and had radiofrequency ablation followed by vertebroplasty. All patients received postoperative multidisciplinary therapy. The operative time, blood loss, complications, pain, neurologic deficit, quality of life, and survival were assessed preoperatively and postoperatively.

Results

Patients were followed from 6 to 56 months. The mean time of operation was 154±50 minutes and the mean blood loss was 210±90 mL. In the pre-operation analysis found the mean visual analogue scale (VAS) was 7.86±0.86. In the post-operation analysis at 3 months, the mean VAS score was 3.51±1.32. The VAS improved significantly (t=7.95, P<0.01). The Frankel grade was improved 1 grade or 2 grades in 14 patients when pre-operation was compared to post-operation. Only 1 patient kept Frankel grade D after surgery. Eight patients with sphincteric dysfunction preoperatively were improved after surgery. The EORTC QLQ-C30 score was 86.13±8.51 preoperatively and 52.21±13.28 postoperatively. The quality of life was improved significantly (t=11.8, P<0.01). The median survival time was 11 months.

Conclusions

Through posterior decompression surgery and radiofrequency ablation followed by vertebroplasty, the quality of life was improved significantly. This palliative treatment was effective and safe in spinal metastasis from lung cancer.

Minimally invasive versus conventional spine surgery for vertebral metastases: a systematic review of the evidence

One of the major determinants of surgical candidacy in patients with symptomatic spinal metastases is the ability of the patient to tolerate the procedure-associated morbidity. In other pathologies, minimally invasive (MIS) procedures have been suggested to have lower intra-operative morbidity while providing similar outcomes. We conducted a systematic review of the PubMed library searching for articles that directly compared the operative and post-operative outcomes of patients treated for symptomatic spinal metastases. Inclusion criteria were articles reporting two or more cases of patients >18 years old treated with MIS or open approaches for spinal metastases. Studies reporting results in spinal metastases patients that could not be disentangled from other pathologies were excluded. Our search returned 1,568 articles, of which 9 articles met the criteria for inclusion. All articles were level III evidence. Patients treated with MIS approaches tended to have lower intraoperative blood loss, shorter operative times, shorter inpatient stays, and fewer complications relative to patients undergoing surgeries with conventional approaches. Patients in the MIS and open groups had similar pain improvement, neurological improvement, and functional outcomes. Recent advances in MIS techniques may reduce surgical morbidity while providing similar symptomatic improvement in patients treated for spinal metastases. As a result, MIS techniques may expand the pool of patients with spinal metastases who are candidates for operative management.

Prognostic Factors of Surgical Complications and Overall Survival of Patients with Metastatic Spinal Tumor

OBJECTIVE

Oncologic treatments increase the incidence of spinal metastases. Surgical treatment of spinal metastases results in a high complication rate, which must set against the expected benefits. The aim of this article was to study the effect of several prognostic factors on surgical complications and survival time using an extended database of patients with spinal metastases.

METHODS

This retrospective study comprised 337 patients with spinal metastases who were surgically treated between 2008 and 2015. Demographic and clinical features, oncologic histories, surgical interventions, and end results were collected. Descriptive statistical methods were used to analyze the cohort of patients. Kaplan-Meier formula and log-rank test were used to examine overall survival times.

RESULTS

Median overall survival time was 222 days (range, 175-274 days). Age, preoperative motor disorders, preoperative Frankel grade categories, Karnofsky performance scale, type of primary tumor, and presence of internal metastasis had a significant negative effect on overall survival. Complications such as bleeding or need for intensive care could be predicted preoperatively based on preoperative performance status, type of primary tumor, affected vertebral levels, and type of surgical interventions.

CONCLUSIONS

Spinal metastatic disease is a challenging surgical problem. If the exact prognostic factors are known preoperatively, surgical outcome and overall survival can be predicted more precisely. Our results could provide a basis for a future multicenter prospective study to determine the best treatment protocol for patients with spinal metastases.

Analysis of Four Scoring Systems for the Prognosis of Patients with Metastasis of the Vertebral Column

OBJECTIVE

Metastatic spinal diseases are common health problems and there is no consensus on the appropriate treatment of metastases in several conditions. Using clinical measures (e.g., survival time and functional status), prognosis prediction systems advise on the appropriate interventions. The aim of this article is to assess and compare 4 widely used scoring systems (revised Tokuhashi, Tomita, van der Linden, and modified Bauer scores) on a single-center cohort.

METHODS

A retrospective study was designed of 329 patients who were subjected to surgery because of metastatic spinal diseases. Subpopulations according to the classifications of the 4 scoring systems were identified. The overall survival was calculated with the Kaplan-Meier formula. The difference between the survival curves of subpopulations was analyzed with log-rank tests. The consistency rates for the 4 scoring systems are calculated as well.

RESULTS

The follow-up period was 8 years. The median survival time was 222 days. The overall survival of prognostic categories in 3 scoring systems was significantly different from each other, but we found no differences between the categories of the van der Linden system. In this cohort, the revised Tokuhashi system gave the best approximation for survival, with a mean predictive capability 60.5%.

CONCLUSIONS

The evaluation of 4 standard scoring systems showed that 3 were self-consistent, although none of systems was able to predict the survival in our cohort. Based on the predictive capability, the revised Tokuhashi system may provide the best predictions with careful examination of individual cases.

Decision Making for the Surgical Treatment of Vertebral Metastases Among Patients with Short Predicted Survival

BACKGROUND

A wide spectrum of treatment choices is proposed for poor-prognosis patients with vertebral metastases. The continuous increase of this population and the propagation of less invasive techniques necessitate further study concerning which patients could benefit from palliative surgery.

METHODS

All patients with a Tokuhashi score ≤8 who had undergone palliative surgical treatment for vertebral metastasis within 4 years were retrospectively reviewed. Demographics, clinical characteristics, and data concerning the disease and the operation were recorded. Patients were assessed on discharge and at 2 months concerning eventual benefit from surgery, based on pain measurements, motor function (Frankel grade), spinal stability assessment, and complications. Statistical analysis was performed to detect possible interrelations.

RESULTS

Eighty-eight patients were reviewed. The average age was 56.5 years. The mean Tokuhashi score was 5.9, and the mean Karnofsky score was 56.4. Thirty-six patients experienced immediate improvement, 12 were lost to follow-up, and 42 were found to have benefited from surgery 2 months later. High Karnofsky score, radicular pain, morphine use, absence of complications, and immediate improvement predicted benefit from surgery.

CONCLUSIONS

Decision making for a patient with poor prognosis concerning eventual surgery for a vertebral metastasis should be based mainly on the patient's clinical presentation; the primary cancer site is of less importance.

Prognostic factors in patients with spinal metastasis: a systematic review and meta-analysis

BACKGROUND CONTEXT

Incidence of symptomatic spinal metastasis has increased owing to improvement in treatment of the disease. One of the key factors that influences decision-making is expected patient survival. To our knowledge, no systematic reviews or meta-analysis have been conducted that review independent prognostic factors in spinal metastases.

PURPOSE

This study aimed to determine independent prognostic factors that affect outcome in patients with metastatic spine disease.

STUDY DESIGN

This is a systematic literature review and meta-analysis of publications for prognostic factors in spinal metastatic disease.

PATIENT SAMPLE

Pooled patient results from cohort and observational studies.

OUTCOME MEASUREMENT

Meta-analysis for poor prognostic factors as determined by hazard ratio (HR) and 95% confidential interval (95% CI).

METHODS

We systematically searched relevant publications in PubMed and Embase. The following search terms were used: ("'spinal metastases'" OR "'vertebral metastases'" OR ""spinal metastasis" OR 'vertebral metastases') AND ('"prognostic factors"' OR "'survival'"). Inclusion criteria were prospective and retrospective cohort series that report HR and 95% CI of independent prognostic factors from multivariate analysis. Two reviewers independently assessed all papers. The quality of included papers was assessed by using Newcastle-Ottawa Scale for cohort studies and publication bias was assessed by using funnel plot, Begg test, and Egger test. The prognostic factors that were mentioned in at least three publications were pooled. Meta-analysis was performed using HR and 95% CI as the primary outcomes of interest. Heterogeneity was assessed using the I² method.

RESULTS

A total of 3,959 abstracts (1,382 from PubMed and 2,577 from Embase) were identified through database search and 40 publications were identified through review of cited publications. The reviewers selected a total of 51 studies for qualitative synthesis and 43 studies for meta-analysis. Seventeen poor prognostic factors were identified. These included presence of a neurologic deficit before surgery, non-ambulatory status before radiotherapy (RT), non-ambulatory status before surgery, presence of bone metastases, presence of multiple bone metastases (>2 sites), presence of multiple spinal metastases (>3 sites), development of motor deficit in <7 days before initiating RT, development of motor deficit in <14 days before initiating RT, time interval from cancer diagnosis to RT <15 months, Karnofsky Performance Score (KPS) 10-40, KPS 50-70, KPS<70, Eastern Cooperative Oncology Group (ECOG) grade 3-4, male gender, presence of visceral metastases, moderate growth tumor on Tomita score (TS) classification, and rapid growth tumor on TS classification.

CONCLUSIONS

Seventeen independent poor prognostic factors were identified in this study. These can be categorized into cancer-specific and nonspecific prognostic factors. A tumor-based prognostic scoring system that combines all specific and general factors may enhance the accuracy of survival prediction in patients with metastatic spine disease.

Symptomatic spinal metastasis: A systematic literature review of the preoperative prognostic factors for survival, neurological, functional and quality of life in surgically treated patients and methodological recommendations for prognostic studies

Purpose

While several clinical prediction rules (CPRs) of survival exist for patients with symptomatic spinal metastasis (SSM), these have variable prognostic ability and there is no recognized CPR for health related quality of life (HRQoL). We undertook a critical appraisal of the literature to identify key preoperative prognostic factors of clinical outcomes in patients with SSM who were treated surgically. The results of this study could be used to modify existing or develop new CPRs.

Methods

Seven electronic databases were searched (1990–2015), without language restriction, to identify studies that performed multivariate analysis of preoperative predictors of survival, neurological, functional and HRQoL outcomes in surgical patients with SSM. Individual studies were assessed for class of evidence. The strength of the overall body of evidence was evaluated using GRADE for each predictor.

Results

Among 4,818 unique citations, 17 were included; all were in English, rated Class III and focused on survival, revealing a total of 46 predictors. The strength of the overall body of evidence was very low for 39 and low for 7 predictors. Due to considerable heterogeneity in patient samples and prognostic factors investigated as well as several methodological issues, our results had a moderately high risk of bias and were difficult to interpret.

Conclusions

The quality of evidence for predictors of survival was, at best, low. We failed to identify studies that evaluated preoperative prognostic factors for neurological, functional, or HRQoL outcomes in surgical patients with SSM. We formulated methodological recommendations for prognostic studies to promote acquiring high-quality evidence to better estimate predictor effect sizes to improve patient education, surgical decision-making and development of CPRs.

Impact of spinal cord compression from intradural and epidural spinal tumors on perioperative symptoms-implications for surgical decision making

Spinal cord or cauda equina compression (SCC) is an increasing challenge in clinical oncology due to a higher prevalence of long-term cancer survivors. Our aim was to determine the clinical relevance of SCC regarding patient outcome depending on different tumor entities and their anatomical localization (extradural/intradural/intramedullary). We retrospectively analyzed 230 patients surgically treated for SCC. Preoperative status for pain and neurological impairment were correlated to the degree of compression, tumor location, and early as well as short-term follow-up outcome parameters. Interestingly, we did not observe any differences between intradural-extramedullary compared to extradural tumors. Unilaterally localized tumors were likely to present with pain (72.9 %, p < 0.01), whereas concentric growth was associated with motor deficits (41.0 %, p < 0.01, as primary symptom, 49.3 % on admission, p < 0.05). In concentric tumors, the pain pattern was diffuse (40.5 % vs. 17.5 in unilateral disease, p < 0.01), whereas unilateral tumors resulted in localized pain (61.4 % local axial or radicular, p < 0.01). Diffuse pain, patients without a sensory or motor deficit, progressive disease, cervical localization, and a higher degree of stenosis were identified as beneficial for an early improvement in pain (p < 0.05). Notably, 29 % of patients with unchanged pain and 30.8 % with unchanged neurologic function at day 7 postoperative improved during follow-up (p < 0.001). Our data demonstrate that the preoperative tumor anatomy in patients with SCC was closely related to their presenting symptoms and early clinical outcome. The detailed analysis elucidates the biology of SCC and might thereby aid in determining which patients will benefit from surgery.

PATIENTS WITH SPINAL METASTASIS SUBMITTED TO NEUROLOGICAL DECOMPRESSION AND STABILIZATION

ABSTRACT Objective: To analyze retrospectively the surgical outcomes of a group of patients with bone metastases and multiple myeloma in the spine, which underwent neurological decompression and arthrodesis using pedicle screws, by isolated posterior approach, to check whether the operated patients present clinical improvement regarding the pain and neurological deficit compared to the preoperative period. Methods: This is a retrospective, cross-sectional study of case series, that analyzed data from medical records of patients with bone metastases in the spine who underwent surgical treatment between January 2007 and February 2011. Results: Of the 42 patients in the sample, according to the Kolmogorov-Smirnov test (p=0.000) there was improvement in pain with respect to the preoperative, with 33 patients (78.6%) reporting improvement and only 9 (21.4%) maintaining the initial pain complaints. Of the 25 patients available for evaluation of neurological improvement (≠ Frankel E) 9 patients (36%) had some kind of improvement postoperatively, and no operated patient presented neurological worsening, indicating statistical significance according to the Kolmogorov-Smirnov test (p = 0.000). It was also observed statistical correlation (p=0.042) between Frankel functional score postoperatively and pain relief, using the chi-square test. Conclusions: Surgical treatment for patients with spinal metastasis through arthrodesis with pedicle instrumentation and decompression may have significant clinical benefits, especially as regards the improvement in pain symptoms and improved neurological function.

Validation of DWI in assessment of radiotreated bone metastases in elderly patients

Bone metastases are commonly observed in oncologic patients with advanced disease. These metastases are considered the main cause of neoplastic pain, with more than half of oncologic patients experiencing neoplastic pain during the course of the disease due to bone involvement. Lung, breast, and prostate cancers are the primary causes of bone metastases. Magnetic resonance imaging (MRI), especially diffusion weighted imaging (DWI) sequences, is the focus of our research, as it has been proven to be an optimal predictive index to assess the radiation treatment in many patients. We included patients treated with standard fractioning of radiation therapy. First, we examined the irradiated lesions with the MRI-DWI technique, before treatment and 30 and 60 days after its completion. Then we combined the MRI results and clinical parameters in a table with a predictive score for the quality of life in patients with bone metastases. This was a significant predictor of the efficacy of radiation treatment, from both clinical and psychological points of view, as it can allow an early assessment of the response to RT and therefore better scheduling of the next therapeutic steps to be performed. The table of the score we proposed helped guide patient monitoring, enabling us to undertake, where possible, follow-up with therapeutic strategies tailored to each patient's needs.

Predictors of 30- and 90-Day Survival Following Surgical Intervention for Spinal Metastases: A Prognostic Study Conducted at Four Academic Centers

STUDY DESIGN

A retrospective review.

OBJECTIVE

We sought to use data from 4 tertiary medical centers to explore surgical, medical, and demographic factors that influence survival within the first 90 days following surgery for spinal metastases.

SUMMARY OF BACKGROUND DATA

Over the last 2 decades, patients with spinal metastases have become more likely to receive surgical intervention. The impact of surgical intervention and its potential benefits must be weighed against the risk of complications and peri-operative mortality. Risk factors that elevate the risk of mortality in the acute postoperative period are not well understood.

METHODS

All records of patients who underwent surgery for metastatic spinal disease at 1 of 4 academic medical centers in New England from 2007 to 2013 were obtained. Patient demographics, tumor characteristics, medical comorbidities, nutritional and functional status, as well as surgical variables were abstracted. Mortality was assessed for patients at 30 and 90 days following the procedure. Factors predictive of survival were assessed using bivariate logistic regression. Those factors with P values < 0.20 in the bivariate assessment were included in a final multivariable model that adjusted for confounders.

RESULTS

Between 2007 and 2013, 318 patients received surgical intervention for metastatic disease involving the spine. Cancer type did not influence the odds of survival at 30 days, while nutritional status and ambulatory capacity increased survival. Lung cancer significantly decreased the odds of survival at 90 days following surgery (odds ratio 0.36; 95% confidence interval 0.18-0.72), while ambulatory function and nutritional status remained significantly associated with improved survival.

CONCLUSION

This effort is one of the first to identify predictors of acute postoperative survival in a large series of patients treated for spinal metastases. Improved nutritional status and ambulatory function may enhance postoperative survival among individuals who undergo surgical intervention for spinal metastases.

LEVEL OF EVIDENCE

3.

Comparison of the therapeutic effects of surgery combined with postoperative radiotherapy and standalone radiotherapy in treating spinal metastases of lung cancer

OBJECT

There are few studies comparing the therapeutic efficacy between surgery combined with postoperative radiotherapy and standalone radiotherapy in treating spinal metastases of lung cancer. The aim of this clinical study was to compare the clinical and functional efficacy, quality of life, and survival outcomes between surgery combined with postoperative radiotherapy and standalone radiotherapy in treating spinal metastases of lung cancer.

METHODS

A retrospective analysis of clinical data from June 2008 to December 2013 was performed with 46 patients suffering spinal metastases of lung cancer. Among the studied patients, 25 patients received standalone radiotherapy (radiotherapy group), and the other 21 patients received surgery combined with postoperative radiotherapy (surgery group). Follow-up and survival time were analyzed. Pain levels of the patients were assessed by visual analogue scale (VAS) from pre-treatment to one month and three months after starting treatment. 3 months after surgery, Neurologic deficit of the patients was evaluated using Frankel Grade, and functional impairment were classified by Karnofsky Score. The quality of life (QOL) was assessed by EORTC QLQ-C30 questionnaire.

RESULTS

The follow-up period of the patients ranged from 2 to 25 months with the average of 8.8 months. In radiotherapy group, the mean survival was 8.5 months with median survival time of 7.8 months. In surgery group, the mean survival was 10.6 months with median survival of 8.4 months. The difference in survival times between the two groups was not statistically significant (P=0.24>0.05). From pre-treatment to one month and three months after treatment initiation, the VAS in both groups showed statistical significant improvement (One month: P<0.01 Three months: P=0.001, p<<0.01). In the surgery group, 85.7% of all patients had functionally useful Frankel Grade D or E after surgery, compared with 71.4% pre-operatively. The percentage was 72.0% in the radiotherapy group post-treatment, compared with 68.0% pre-treatment. The relief of Frankel Grade in surgical group was superior to that of the radiotherapy group (p=0.025, p<0.01). KPS score (80-100) percentages in surgery group and in radiotherapy group were increased by 19% and 13.3%, respectively. The improvement of KPS was more in the surgery group (p=0.013, P<0.01). In radiotherapy group, the EORTC QLQ-C30 score was 86.13 ± 12.11 before treatment and 68.39 ± 14.96 after treatment. In surgery group, the EORTC QLQ-C30 score was 84.09 ± 9.48 before treatment and 54.64 ± 15.17 after treatment. The improvement of patient QOL was more in the surgery group (p=0.004, p<0.01).

CONCLUSION

Compared with standalone radiotherapy, surgery combined with postoperative radiotherapy did not significantly prolong the survival time. However, surgery can improve pain, function and QOL of patients with spinal metastases of lung cancer.

Factors affecting survival in 43 consecutive patients after surgery for spinal metastases from thyroid carcinoma

OBJECT

Spinal metastases account for the majority of bone metastases from thyroid cancer. The objective of the current study was to analyze a series of consecutive patients undergoing spinal surgery for thyroid cancer metastases in order to identify factors that influence overall survival.

METHODS

The authors retrospectively reviewed the records of all patients who underwent surgery for spinal metastases from thyroid cancer between 1993 and 2010 at the University of Texas MD Anderson Cancer Center.

RESULTS

Forty-three patients met the study criteria. Median overall survival was 15.4 months (95% CI 2.8-27.9 months) based on the Kaplan-Meier method. The median follow-up duration for the 4 patients who were alive at the end of the study was 39.4 months (range 1.7-62.6 months). On the multivariate Cox analysis, progressive systemic disease at spine surgery and postoperative complications were associated with worse overall survival (HR 8.98 [95% CI 3.46-23.30], p < 0.001; and HR 2.86 [95% CI 1.30-6.31], p = 0.009, respectively). Additionally, preoperative neurological deficit was significantly associated with worse overall survival on the multivariate analysis (HR 3.01 [95% CI 1.34-6.79], p = 0.008). Conversely, preoperative embolization was significantly associated with improved overall survival on the multivariate analysis (HR 0.43 [95% CI 0.20-0.94], p = 0.04). Preoperative embolization and longer posterior construct length were significantly associated with fewer and greater complications, respectively, on the univariate analysis (OR 0.24 [95% CI 0.06-0.93] p = 0.04; and OR 1.24 [95% CI 1.02-1.52], p = 0.03), but not the multivariate analysis.

CONCLUSIONS

Progressive systemic disease, postoperative complications, and preoperative neurological deficits were significantly associated with worse overall survival, while preoperative spinal embolization was associated with improved overall survival. These factors should be taken into consideration when considering such patients for surgery. Preoperative embolization and posterior construct length significantly influenced the incidence of postoperative complications only on the univariate analysis.

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.

Primary Spinal Tumor Mortality Score (PSTMS): a novel scoring system for predicting poor survival

BACKGROUND CONTEXT

Although the surgical and oncological therapies of primary spinal tumors (PSTs) have changed significantly over the last few decades, the prognosis of this rare disease is still poor. The decision-making process in the multidisciplinary management is handicapped by the lack of large-scale population-based prognostic studies.

PURPOSE

The objective of the present study was to investigate preoperative factors associated with PST mortality and to develop a predictive scoring system of poor survival.

STUDY DESIGN

This is a large-scale ambispective cohort study.

PATIENT SAMPLE

The study included 323 consecutive patients with PSTs, treated surgically over an 18-year period at a tertiary care spine referral center for a population of 10 million.

OUTCOME MEASURE

Survival was the outcome measure.

METHODS

Patients were randomly divided into a training cohort (n=273) and a validation cohort (n=50). In the training cohort, 12 preoperative factors were investigated using Cox proportional hazard models. Based on the mortality-related variables, a simple scoring system of mortality was created, and three groups of patients were identified. Kaplan-Meier and log-rank analyses were used to compare the survival in the three groups. The model performance was assessed by measuring the discriminative ability (c-index) of the model and by applying a pseudo-R(2) goodness-of-fit test (Nagelkerke R(2), RN(2)). Internal validation was performed using bootstrapping in the training cohort and assessing the discrimination and explained variation of the model in the validation cohort.

RESULTS

Patient age, spinal region, tumor grade, spinal pain, motor deficit, and myelopathy/cauda equina syndrome were significantly associated with poor survival in the multivariate analysis (p<.001, RN(2)=0.799). Based on these variables, we developed the Primary Spinal Tumor Mortality Score (PSTMS), where an eight-point scale was divided into three categories (low, medium, and high mortality). The three PSTMS categories were significantly associated with the overall survival (p<.001, RN(2)=0.811, c=0.82). The model performance remained similarly high in the validation cohort (RN(2)=0.831, c=0.81).

CONCLUSIONS

The present study identifies six predictive variables for mortality in PSTs. Using these six variables, an easy-to-use scoring system was developed that can be applied to the estimation of postoperative survival in all types of PST patients.

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.

Factors affecting survival in 267 consecutive patients undergoing surgery for spinal metastasis from renal cell carcinoma

OBJECT

Renal cell carcinoma (RCC) frequently metastasizes to the spine, and the prognosis can be quite variable. Surgical removal of the tumor with spinal reconstruction has been a mainstay of palliative treatment. The ability to predict prognosis is valuable when determining the role and magnitude of surgical intervention in cancer patients. To better identify factors affecting survival in patients undergoing surgery for spinal metastasis from RCC, the authors undertook a retrospective analysis of a large patient cohort at a tertiary care cancer center.

METHODS

Relevant clinical data on a consecutive series of patients who had undergone surgery for spinal metastasis of RCC between 1993 and 2007 at The University of Texas MD Anderson Cancer Center were retrospectively reviewed. Demographic data, histopathological grade of primary tumor, timing of spinal surgery relative to diagnosis, treatment history prior to surgery, neurological status, and systemic disease burden were analyzed to determine the impact of these factors on survival outcome.

RESULTS

The authors identified 267 patients who met the study criteria. Five-year overall survival (OS) after spine tumor resection was 7.8%, with a median OS of 11.3 months (95% CI 9.5-13.0 months). Patients with Fuhrman Grade 4 RCC had a median OS of 6.1 months (95% CI 3.5-8.7 months), which was significantly lower than the 14.3 months (95% CI 9.1-19.4 months) observed in patients with Fuhrman Grade 3 or less RCC (p < 0.001). Patients with preoperative neurological deficits had a median survival of 5.9 months (95% CI 4.1-7.7 months), which was significantly lower than the 13.5 months (95% CI 10.4-16.6 months) observed in patients with a normal neurological examination (p < 0.001). Patients whose spine was the only site of metastasis had a median OS of 19 months (95% CI 9.8-28.2 months) after surgery, significantly longer than the 9.7 months (95% CI 8.1-11.3 months) observed in patients with additional extraspinal metastasis sites (p < 0.001). Patients with nonprogressing extraspinal metastasis (no metastasis, stable, or concurrent) had a median survival of 20.6 months (95% CI 15.1-26.1 months), compared with 5.6 months (95% CI 4.4-6.8 months) in patients with progressing metastasis (p < 0.001).

CONCLUSIONS

The authors identified several factors influencing survival after spine surgery for metastatic spinal RCC, including grade of the original nephrectomy specimen, activity of the systemic disease, and neurological status at the time of surgery. These clinical features may help to identify patients who may benefit from aggressive surgical intervention.

[Management of spinal metastases of lung cancer]

INTRODUCTION

Spinal metastases of lung cancer occur frequently and lead to the risk of spinal cord compression. Our objective is to clarify the management of this disease, emphasizing, in particular the use of prognostic scores.

BACKGROUND

The first step is to evaluate the characteristics of the spinal lesion and its impact on the autonomy and quality of life of the patient. A clinical examination is complemented by imaging procedures, such as X-rays, MRI of the spine, and PET scanning. The precise characterization of the spinal lesion permits the calculation of a predictive score for mechanical stability. The characteristics of the disease (number of metastatic sites, therapeutic possibilities, co-morbidities) can be used in decision-making.

VIEWPOINTS

The use of prognostic scores is recommended by the Global Spine Tumour Study Group (GSTSG) for the management of spinal metastases. Among these scores, the most used are the Tokuhashi index, and the Tomita classification. They help to identify the treatment modalities, sometimes combined that might be used in the management: surgery, vertebral resection, tumour embolisation, radiotherapy, chemotherapy.

CONCLUSIONS

The management of spinal metastases of lung cancer should be multidisciplinary. Use of prognostic scores should be encouraged to identify optimal management.

Factors Associated With Improved Outcomes Following Decompressive Surgery for Prostate Cancer Metastatic to the Spine

BACKGROUND:

Metastatic spinal cord compression from prostate cancer is a debilitating disease causing neurological deficits, mechanical instability, and intractable pain. Surgical management may improve quality of life.

OBJECTIVE:

To define postoperative outcomes and explore associations with prolonged survival for patients with metastatic prostate cancer.

METHODS:

Retrospective chart reviews were performed of all patients undergoing spinal surgery for metastatic cancer from June 1, 2002 to August 31, 2011. Patient demographics, surgical details, adjuvant therapies, outcomes, complications, and postoperative survival were reviewed.

RESULTS:

Twenty-seven patients with prostate cancer underwent surgery at a median age of 65 years (range, 46-82 years). After surgery, 93% of patients had preserved or improved neurological status, 56% of nonambulatory patients recovered ambulation, 43% of incontinent patients recovered continence, and 23% experienced complications. Postoperative Frankel grades were significantly improved by at least 1 letter grade at 1 month (P = .03). The median analgesic and steroid usage was significantly lower up to 3 months and 6 months postoperatively, respectively (P = .007, .005). Median survival following surgery was 10.2 months, and patients with castration-resistant prostate cancer had a shorter median survival than those with hormone-naïve disease (9.8 vs 40 months). Better preoperative performance status was an independent predictor of survival (P = .02). Younger age (P = .005) and instrumentation greater than 7 spinal levels (P = .03) were associated with complications.

CONCLUSION:

Spinal surgery for prostate metastases improves neurological function and decreases analgesic requirements. Our findings support surgical intervention for carefully selected patients, and knowledge of preoperative hormone sensitivity and performance status may help with risk stratification.

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.

Spinal metastasis in thyroid cancer

BACKGROUND

Thyroid carcinoma generally responds well to treatment and spinal metastasis is an uncommon feature. Many studies have looked at the management of spinal metastasis and proposed treatments, plans and algorithms. These range from well-established methods to potentially novel alternatives including bisphosphonates and vascular endothelial growth factor (VEGF) therapy, amongst others.The purposes of this systematic review of the literature are twofold. Firstly we sought to analyse the proposed management options in the literature. Then, secondly, we endeavoured to make recommendations that might improve the prognosis of patients with spinal metastasis from thyroid carcinomas.

METHODS

We conducted an extensive electronic literature review regarding the management of spinal metastasis of thyroid cancer.

RESULTS

We found that there is a tangible lack of studies specifically analysing the management of spinal metastasis in thyroid cancer. Our results show that there are palliative and curative options in the management of spinal metastasis, in the forms of radioiodine ablation, surgery, selective embolisation, bisphosphonates and more recently the VEGF receptor targets.

CONCLUSIONS

The management of spinal metastasis from thyroid cancer should be multi-disciplinary. There is an absence; it seems, of a definitive protocol for treatment. Research shows increased survival with 131I avidity and complete bone metastasis resection. Early detection and treatment therefore are crucial. Studies suggest in those patients below the age of 45 years that treatment should be aggressive, and aim for cure. In those patients in whom curative treatment is not an option, palliative treatments are available.

Predictive value of Tokuhashi scoring systems in spinal metastases, focusing on various primary tumor groups: evaluation of 448 patients in the Aarhus spinal metastases database

STUDY DESIGN

We conducted a prospective cohort study of 448 patients with spinal metastases from a variety of cancer groups.

OBJECTIVE

To determine the specific predictive value of the Tokuhashi scoring system (T12) and its revised version (T15) in spinal metastases of various primary tumors.

SUMMARY OF BACKGROUND DATA

The life expectancy of patients with spinal metastases is one of the most important factors in selecting the treatment modality. Tokuhashi et al formulated a prognostic scoring system with a total sum of 12 points for preoperative prediction of life expectancy in 1990 and revised it in 2005 to a total sum of 15 points. There is a lack of knowledge about the specific predictive value of those scoring systems in patients with spinal metastases from a variety of cancer groups.

METHODS

We included 448 patients with vertebral metastases who underwent surgical treatment during November 1992 to November 2009 in Aarhus University Hospital NBG. Data were retrieved from Aarhus Metastases Database. Scores based on T12 and T15 were calculated prospectively for each patient. We divided all the patients into different groups dictated by the site of their primary tumor. Predictive value and accuracy rate of the 2 scoring systems were compared in each cancer group.

RESULTS

Both the T12 and T15 scoring systems showed statistically significant predictive value when the 448 patients were analyzed in total (T12, P < 0.0001; T15, P < 0.0001). The accuracy rate was significantly higher in T15 (P < 0.0001) than in T12. The further analyses by primary cancer groups showed that the predictive value of T12 and T15 was primarily determined by the prostate (P = 0.0003) and breast group (P = 0.0385). Only T12 displayed predictive value in the colon group (P = 0.0011). Neither of the scoring systems showed significant predictive value in the lung (P > 0.05), renal (P > 0.05), or miscellaneous primary tumor groups (P > 0.05). The accuracy rate of prognosis in T15 was significantly improved in the prostate (P = 0.0032) and breast group (P < 0.0001).

CONCLUSION

Both T12 and T15 showed significant predictive value in patients with spinal metastases. T15 has a statistically higher accuracy rate than T12. Among the various cancer groups, the 2 scoring systems are especially reliable in prostate and breast metastases groups. T15 is recommended as superior to T12 because of its higher accuracy rate.

Multidisciplinary treatment and survival of patients with vertebral metastases from thyroid carcinoma

BACKGROUND

Distant metastases from differentiated thyroid carcinoma occur in up to 20% of cases and represent the most frequent cause of thyroid cancer-related death. Metastatic disease to the spine has the potential to cause severe morbidity, including pain, neurological deficit, and paraplegia.

SUMMARY

We present a case series of eight consecutive patients with symptomatic spinal metastases due to thyroid carcinoma treated by our multidisciplinary team consisting of spinal surgeons, oncologists, and radiologists, with management of each case determined by our surgical algorithm. Four patients underwent surgical decompression and stabilization for spinal metastases causing instability, spinal cord compression, neurological deficit, or intractable pain. Three patients underwent vertebroplasty for focal mechanical pain due to osteolytic metastases in the absence of significant spinal cord compression or spinal instability; one of these patients required subsequent surgical decompression for spinal cord compression. One patient was nonoperatively treated. All patients underwent total thyroidectomy for the primary cancer and adjuvant radioiodine-131 treatment. The only patient with poorly differentiated thyroid cancer, which was refractory to radioiodine-131 died at 6 months after vertebroplasty procedures for symptomatic spinal metastases. One patient with medullary thyroid carcinoma died at 18 months after vertebroplasty. All remaining six patients who had well-differentiated papillary or follicular thyroid carcinoma were alive at an average of 50 months (range: 17-96 months) after diagnosis and treatment of symptomatic spinal metastases and were ambulant, independent, and able to perform activities of daily living and had no significant pain or neurologic symptoms.

CONCLUSION

The potential for long-term survival of several years following development of spinal metastases should be considered during the counseling and decision-making process for patients with thyroid cancer.

Postoperative survival and ambulatory outcome in metastatic spinal tumors : prognostic factor analysis

OBJECTIVE

The purposes of this study are to estimate postoperative survival and ambulatory outcome and to identify prognostic factors thereafter of metastatic spinal tumors in a single institute.

METHODS

We reviewed the medical records of 182 patients who underwent surgery for a metastatic spinal tumor from January 1987 to January 2009 retrospectively. Twelve potential prognostic factors (age, gender, primary tumor, extent and location of spinal metastases, interval between primary tumor diagnosis and metastatic spinal cord compression, preoperative treatment, surgical approach and extent, preoperative Eastern Cooperative Oncology Group (ECOG) performance status, Nurick score, Tokuhashi and Tomita score) were investigated.

RESULTS

The median survival of the entire patients was 8 months. Of the 182 patients, 80 (44%) died within 6 months after surgery, 113 (62%) died within 1 year after surgery, 138 (76%) died within 2 years after surgery. Postoperatively 47 (26%) patients had improvement in ambulatory function, 126 (69%) had no change, and 9 (5%) had deterioration. On multivariate analysis, better ambulatory outcome was associated with being ambulatory before surgery (p=0.026) and lower preoperative ECOG score (p=0.016). Survival rate was affected by preoperative ECOG performance status (p<0.001) and Tomita score (p<0.001).

CONCLUSION

Survival after metastatic spinal tumor surgery was dependent on preoperative ECOG performance status and Tomita score. The ambulatory functional outcomes after surgery were dependent on preoperative ambulatory status and preoperative ECOG performance status. Thus, prompt decompressive surgery may be warranted to improve patient's survival and gait, before general condition and ambulatory function of patient become worse.

Early surgical experience with minimally invasive percutaneous approach for patients with metastatic epidural spinal cord compression (MESCC) to poor prognoses

PURPOSE

This study was designed to assess the impact of minimally invasive surgery (MIS) for the treatment of patients with metastatic epidural spinal cord compression (MESCC) and vertebral body fracture, in terms of feasibility, clinical improvement, and morbidity.

METHODS

Twenty-five consecutive patients with diagnosis of MESCC from solid primary tumors were treated between January 2008 and June 2010 at our institution. All patients, after multidisciplinary assessment, were considered with poor prognosis because of their disease's extension and/or other clinical conditions. Mini-invasive percutaneous surgery was performed in all patients followed by radiotherapy within 2 weeks postoperatively. Clinical outcome was evaluated by modified visual analog scale for pain, Frankel Scale for neurologic deficit, and magnetic resonance imaging or computed tomography scan.

RESULTS

Clinical remission of pain was obtained in the vast majority of patients (96%). Improvement of neurological deficit was observed in 22 patients (88%). No major morbidity or perioperative mortality occurred. The average hospital stay was 6 days. Local recurrence occurred in two patients (8%). Median survival was 10 (range, 6-24) months. Overall survival at 1 year was 43%.

CONCLUSIONS

For patients with MESCC and body fracture, with limited life expectancy, minimally invasive spinal surgery followed by radiotherapy, is feasible and provides clinical benefit in most of patients, with low morbidity. We believe that a minimally invasive approach can be an alternative surgical method compared with more aggressive or demanding procedures, which in selected patients with metastatic spinal cord compression with poor prognosis could represent overtreatment.

Actual and predicted survival time of patients with spinal metastases of lung cancer: evaluation of the robustness of the Tokuhashi score

STUDY DESIGN

In a retrospective analysis we evaluated the achieved and the predicted survival times according to the Tokuhashi score for patients with spinal metastases of lung cancer (lc).

OBJECTIVE

Our aim was to investigate the robustness of the Tokuhashi Score for this group of patients.

SUMMARY OF BACKGROUND DATA

The decision on operative versus conservative treatment for cancer patients with vertebral metastases depend on their predicted lifespan. Although the score of Tokuhashi is commonly used for prognostic predictions, it's reliability for specific tumor types (e.g., lc), has not been validated.

METHODS

Seventy-six patients who had undergone spinal surgery for lc metastases between 1999 and 2004 were verified according to the Tokuhashi score and predicted versus achieved survival times were compared.

RESULTS

The median overall survival (OS) after surgery for all patients was 108 (3-1767) days (102 [5-1767] days for patients with NSCLC [n = 49; 64.5%] and 108 [3-473] days for patients with SCLC [n = 24; 31.6%]). Survival times differed depending on the time period of procedure performance (OS 81 [3-435] days for patients operated between 1999 and 2001 [n = 38], 135 [8-1767] days for patients who received surgery between 2002 and 2004 [n = 38]). Actual and predicted survival were similar in 51 of 76 cases (67.1%), while there was no correlation in 25 of 76 (32.9%) cases. Results were comparable for all histologic subgroups.

CONCLUSION

Although the survival time of patients with vertebral metastases from lc has increased over the last 10 years, the overall outcome is still poor. For the prediction of an individual prognosis in the group of lc patients the score of Tokuhashi seems to be a suboptimal tool. We conclude that therapeutic decisions for such patients should be made based on interdisciplinary platforms, especially in the light of improved systemic treatment options.

A prospective analysis of prognostic factors in patients with spinal metastases: use of the revised Tokuhashi score

STUDY DESIGN

Prospective observational cohort study.

OBJECTIVE

To define the utility of the revised Tokuhashi score in relation to predicting survival in patients with spinal metastases regardless of the treatment pathway.

SUMMARY OF BACKGROUND DATA

The revised Tokuhashi score has been used for the prediction of survival. In this scoring system, however, all the patients were sourced by orthopedic surgeons, and asymptomatic patients were excluded. That might present a significant source of patient selection bias. The treatment plan was also affected by the predicted survival in their system.

METHODS

All patients within 2 years of diagnosis of spinal metastases, whether symptomatic were recruited. Minimum 1-year follow-up was required. During the study period, a total of 85 patients were analyzed including 44 patients who died within 1 year. The relation between the revised Tokuhashi score and survival were analyzed using the Cox proportional hazard model and Spearman's rank correlation coefficient.

RESULTS

The mean age was 60.3 years (range: 35-84) and the median survival was 11.6 months. On multivariate analysis, lower performance status (Karnofsky performance status, 50%-70%) and unresectable organ metastases were significantly associated with poor survival, with hazard ratios of 2.92 and 4.44, respectively. In primary cancer type, lung and kidney cancer were also significantly associated with poor survival, with hazard ratios of 4.25 and 2.60, respectively. The revised Tokuhashi score groups were significantly correlated with the survival groups (ρ = 0.530, P < 0.001). In 67 (79%) of 85 patients, actual survival matched the predicted survival.

CONCLUSION

Lower score on performance status, the existence of organ metastases, and primary cancer of the lung and the kidney were significantly associated with poor survival. The revised Tokuhashi score was found to be very useful to predict survival regardless of the treatment pathway. In most patients, actual survival matched their predicted survival.

Survival prognostic factors and clinical outcomes in patients with spinal metastases

PURPOSE

In patients with metastatic disease to the spine, patient selection for surgery and the extent of surgery to perform thereafter remains controversial, with the patient's survival prognosis the most important consideration. For this reason, we conducted a prospective study investigating prognostic factors and clinical outcomes in a consecutive series of patients with vertebral metastases.

METHODS

A total of 142 consecutive patients with vertebral metastases referred to us for consideration of surgery were prospectively enrolled into this study. Of these, 118 patients subsequently underwent palliative surgery for intractable pain or radiculopathy, bony instability or spinal cord compression. Patients were followed up for 12 months or until death. A multivariate analysis of the patients was conducted using the Cox proportional hazards model. The survival predictive accuracy of the Tokuhashi score was also investigated. For the patients who underwent surgery, pre- and post-operative outcomes were assessed on pain, neurological deficit, function and overall quality of life.

RESULTS

The overall 12-month mortality rate was 50.7% and the median survival was 5 months. Multivariate analysis showed that independent prognostic factors for survival after spinal metastases include primary tumour type, Karnofsky functional status, ASA score and pain. Neither the original nor revised Tokuhashi scores were reliable in predicting survival in our European population. In the patients who underwent operative intervention, there was an immediate and prolonged improvement in pain, neurological deficit, function and quality of life in the majority of cases.

CONCLUSIONS

The potential for rapid and maintained improvement in clinical outcome and quality of life should be considered when selecting patients with metastatic disease to the spine for surgery rather than basing decisions solely on survival prognostic factors comprising current scoring systems.

Patients with cervical metastasis and neoplastic pachymeningitis are less likely to improve neurologically after surgery

BACKGROUND

Although many patients with cervical spine metastases are treated surgically, it is unknown whether certain subsets achieve better pain relief and improvement of neurologic function.

QUESTIONS/PURPOSES

(1) Does tumor removal with reconstruction improve the neurologic status? (2) Is any subset of patients more likely to have neurological recovery from palliative surgery? (3) What is the rate of surgery-related complications?

PATIENTS AND METHODS

We retrospectively reviewed 46 patients who had palliative surgery for metastatic solid tumor metastases of the subaxial cervical spine. Indications were neurologic deficits, life expectancy longer than 6 months, and a Karnofsky Performance Score of 50 to 70. Surgery consisted of anterior tumor removal and reconstruction with titanium mesh cages and/or tricortical iliac crest allograft plus plate fixation or of a combined procedure with adjunctive posterior decompression and stabilization with lateral mass screw fixation. Postoperatively, neurologic Frankel score grade, Karnofsky Performance Score, and complications were recorded.

RESULTS

Five of 18 nonambulatory patients (Frankel B/C) became ambulatory again (Frankel D). No patients were Frankel Grade E preoperatively, whereas 19 of 46 gained Frankel Grade E after surgery. One patient worsened neurologically and died 4 months after surgery. Patients with neoplastic pachymeningitis had less neurologic recovery than those without. Complications included dural tears (three), wound infection (three), and tumor relapse at the same or an adjacent level (four). Two of these four patients had instrumentation-related complications.

CONCLUSIONS

Surgery improved clinical and neurologic status according to Frankel score; patients with neoplastic pachymeningitis are likely to experience less neurologic recovery.

LEVEL OF EVIDENCE

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

Survival prognostic factors and clinical outcomes in patients with spinal metastases

PURPOSE

In patients with metastatic disease to the spine, patient selection for surgery and the extent of surgery to perform thereafter remains controversial, with the patient's survival prognosis the most important consideration. For this reason, we conducted a prospective study investigating prognostic factors and clinical outcomes in a consecutive series of patients with vertebral metastases.

METHODS

A total of 142 consecutive patients with vertebral metastases referred to us for consideration of surgery were prospectively enrolled into this study. Of these, 118 patients subsequently underwent palliative surgery for intractable pain or radiculopathy, bony instability or spinal cord compression. Patients were followed up for 12 months or until death. A multivariate analysis of the patients was conducted using the Cox proportional hazards model. The survival predictive accuracy of the Tokuhashi score was also investigated. For the patients who underwent surgery, pre- and post-operative outcomes were assessed on pain, neurological deficit, function and overall quality of life.

RESULTS

The overall 12-month mortality rate was 50.7% and the median survival was 5 months. Multivariate analysis showed that independent prognostic factors for survival after spinal metastases include primary tumour type, Karnofsky functional status, ASA score and pain. Neither the original nor revised Tokuhashi scores were reliable in predicting survival in our European population. In the patients who underwent operative intervention, there was an immediate and prolonged improvement in pain, neurological deficit, function and quality of life in the majority of cases.

CONCLUSIONS

The potential for rapid and maintained improvement in clinical outcome and quality of life should be considered when selecting patients with metastatic disease to the spine for surgery rather than basing decisions solely on survival prognostic factors comprising current scoring systems.

Outcome of Surgical Treatment for Metastatic Vertebra Bone Tumor in Advanced Lung Cancer

Background

Spinal metastases of patients with advanced stage lung cancer are an important target for palliative therapy, because their incidence is high, and they often cause severe symptoms and worsen the quality of life. Surgery is one of the most effective treatment options, but the indication of surgery is unclear as the procedure is invasive and patients with spinal metastasis have a rather short life expectancy. Furthermore, there have been few studies that have focused on lung cancer with poor prognosis.

Methods

We reviewed all of the cases of lung cancer from January 1999 to July 2007 in the Department of Respiratory Medicine, Kyoto University Hospital, Japan. Thirteen patients with metastatic spinal tumor of lung cancer underwent surgery, and all of them had a poor performance status score (3 or 4).

Results

Neurological improvement by at least 1 Frankel grade was seen in 10 of 14 cases (71%). Improvement of the movement capacity was noted in 9 of 14 cases (64%), and pain improvement was noted in 12 of 14 (86%). Median postoperative survival was 5 months (1–25 months). In particular, the group with a good postoperative performance status score (0–2) was shown to have a better median postoperative survival of 13 months.

Conclusions

Surgical treatment for symptomatic metastatic spinal tumor of lung cancer can improve quality of life in a substantially high percentage of patients. Surgery should be considered even if preoperative performance status is poor.

Review of metastatic spine tumour classification and indications for surgery: the consensus statement of the Global Spine Tumour Study Group

Choosing the right operation for metastatic spinal tumours is often difficult, and depends on many factors, including life expectancy and the balance of the risk of surgery against the likelihood of improving quality of life. Several prognostic scores have been devised to help the clinician decide the most appropriate course of action, but there still remains controversy over how to choose the best option; more often the decision is influenced by habit, belief and subjective experience. The purpose of this article is to review the present systems available for classifying spinal metastases, how these classifications can be used to help surgical planning, discuss surgical outcomes, and make suggestions for future research. It is important for spinal surgeons to reach a consensus regarding the classification of spinal metastases and surgical strategies. The authors of this article constitute the Global Spine Tumour Study Group: an international group of spinal surgeons who are dedicated to studying the techniques and outcomes of surgery for spinal tumours, to build on the existing evidence base for the surgical treatment of spinal tumours.

Survival rate and neurological outcome after operation for advanced spinal metastasis (Tomita's classification > or = type 4)

PURPOSE

We investigated whether primary malignancy entities and the extent of tumor resection have an effect on the survival rate and neurological improvement in patients with spinal metastases that extend beyond the vertebral compartment (Tomita's classification > or = type 4).

MATERIALS AND METHODS

We retrospectively reviewed 87 patients with advanced spinal metastasis who underwent surgery. They were divided into groups 1 and 2 according to whether they responded to adjuvant therapy or not, respectively. They were subdivided according to the extent of tumor resection: group 1, gross total resection (G1GT); group 1, subtotal resection (G1ST); group 2, gross total resection (G2GT); and group 2, subtotal resection (G2ST). The origin of the tumor, survival rate, extent of resection, and neurological improvement were analyzed.

RESULTS

Group 1 had a better survival rate than group 2. The G1GT subgroup showed a better prognosis than the G1ST subgroup. In group 2, the extent of tumor resection (G2GT vs. G2ST) did not affect survival rate. In all subgroups, neurological status improved one month after surgery, however, the G2ST subgroup had worsened at the last follow-up. There was no local recurrence at the last follow-up in the G1GT subgroup. Four out of 13 patients in the G2GT subgroup showed a local recurrence of spinal tumors and progressive worsening of neurological status.

CONCLUSION

In patients with spinal metastases (Tomita's classification > or = type 4), individuals who underwent gross total resection of tumors that responded to adjuvant therapy showed a higher survival rate than those who underwent subtotal resection. For tumors not responding to adjuvant therapy, we suggest palliative surgical decompression.

Surgical management of prostate cancer metastatic to the spine

Object

Significant improvements in neurological function and pain relief are the benefits of aggressive surgical management of spinal metastatic disease. However, there is limited literature regarding the management of tumors with specific histological features. In this study, a series of patients undergoing spinal surgery for metastatic prostate cancer were reviewed to identify predictors of survival and functional outcome.

Methods

The authors retrospectively reviewed the records of all patients who were treated with surgery for prostate cancer metastases to the spine between 1993 and 2005 at a single institution. Particular attention was given to initial presentation, operative management, clinical and neurological outcomes, and factors associated with complications and overall survival.

Results

Forty-four patients underwent a total of 47 procedures. The median age at spinal metastasis was 66 years (range 50–84 years). Twenty-four patients had received previous external-beam radiation to the site of spinal involvement, with a median dose of 70 Gy (range 30–74 Gy). Frankel scores on discharge were significantly improved when compared with preoperative scores (p = 0.001). Preoperatively, 32 patients (73%) were walking and 33 (75%) were continent. On discharge, 36 (86%) of 42 patients were walking, and 37 (88%) of 42 were continent. Preoperatively, 40 patients (91%) were taking narcotics, with a median morphine equivalent dose of 21.5 mg/day, and 28 patients (64%) were taking steroids, with a median dose of 16 mg/day. At discharge, the median postoperative morphine equivalent dose was 12 mg/day, and the median steroid dose was 0 mg/day (p < 0.001). Complications occurred in 15 (32%) of 47 procedures, with 9 (19%) considered major, and there were 4 deaths within 30 days of surgery. The median overall survival was 5.4 months. Gleason score (p = 0.002), total number of metastases (p = 0.001), and the degree of spinal canal compression (p = 0.001) were independent predictors of survival. Age ≥ 65 years at the time of surgery was an independent predictor of a postoperative complication (p = 0.005).

Conclusions

In selected patients with prostate cancer metastases to the spine, aggressive surgical decompression and spinal reconstruction is a useful treatment option. The results show that on average, neurological outcome is improved and use of analgesics is reduced. Gleason score, metastatic burden, and degree of spinal canal compression may be associated with survival following surgery, and thus should be considered carefully prior to opting for surgical management.

Changes in physical function after palliative surgery for metastatic spinal tumor: association of the revised Tokuhashi score with neurologic recovery

STUDY DESIGN

A retrospective study of patients undergoing palliative surgery for metastatic spinal tumors.

OBJECTIVE

To investigate short-term functional recovery and duration of improvement after palliative surgery, to correlate these outcomes with the revised Tokuhashi score, and to examine the relationship between function and neurologic deterioration.

SUMMARY OF BACKGROUND DATA

The revised Tokuhashi score is a scoring system used to predict life expectancy for patients with metastatic spinal tumors. The relationship between the revised Tokuhashi score and physical functional improvement after palliative surgery has not been examined previously.

METHODS

The clinical charts of 86 patients were reviewed. The Eastern Cooperative Oncology Group Performance Status (ECOG-PS) was used to assess physical function. Each score was documented before surgery and at every month after surgery. The duration of ECOG-PS improvement, defined as the period between surgery and deterioration to the preoperative ECOG-PS grade, was correlated with the revised Tokuhashi score.

RESULTS

The ECOG-PS grade improved in 44 (51.1%) patients at 1 month postoperative. When ECOG-PS improvement was found after surgery, it persisted above the preoperative level for an average of 9.3 months. At 1 month postoperative, patients scoring 0 to 8 on the total revised Tokuhashi score had significantly lower ECOG-PS improvement (26 of 55 patients) when compared to patients with higher scores (18 of 27 patients, P < 0.05). In 44 patients with ECOG-PS improvement, the existence of major internal organ metastases significantly shortened the duration of improvement (P < 0.05).

CONCLUSION

Palliative surgery benefited half of the patients with metastatic spinal tumor, with a greater probability of benefit found in persons with a higher total revised Tokuhashi score (score 9-15) and/or primary cancers with longer survival times.

Surgical results of metastatic spinal cord compression secondary to non-small cell lung cancer

STUDY DESIGN

The results for 37 surgical interventions in 31 consecutive patients with non-small cell lung cancer (NSCLC) with symptomatic spinal cord compression were reviewed retrospectively.

OBJECTIVES

To evaluate postoperative outcomes and survival rates of NSCLC patients surgically treated for symptomatic spinal metastasis.

SUMMARY OF BACKGROUND DATA

For patients with spinal cord compression secondary to lung cancer, the prognosis is usually poor. However, with the development of new chemotherapeutic drugs and targeted therapeutic agents, the survival rate may be better.

METHODS

From November 2000 to March 2005, 31 patients with symptomatic metastatic spinal cord compression secondary to NSCLC underwent palliative surgery using a posterolateral transpedicular approach (PTA) or combined posterior and anterior procedures. The indication for surgery was neurologic progression due to spinal cord compression.

RESULTS

The patients ranged in age from 20 to 81 years (mean, 61.4 years). Twenty-eight patients (90%) underwent PTA, and 3 patients had combined posterior and anterior procedures. Neurologic improvement by at least one Frankel grade was noted in 25 of 31 cases (80%). Overall, 74% of patients (23 of 31) were able to walk after surgery. There was no case of intraoperative mortality, but two deaths occurred in the postoperative period. Median survival time was 8.8 months.

CONCLUSIONS

Even though lung cancer is considered an aggressive tumor, it is justifiable to aggressively treat patients with symptomatic spinal cord compression. Surgery by PTA can lead to good results in these patients.

Chirurgisches Management von Wirbelsäulenmetastasen

The spine is the most frequent site of skeletal metastases. Among all spinal malignancies metastatic disease is most frequent and indicative of disseminating tumor disease. Depending on primary tumor entity, estimated survival time, general health status of the patient, presence of spinal instability and neurological deficits an oncological useful and patient-specific therapeutic intervention should be performed. New anterior approaches, resections and reconstruction techniques are making surgery a preferred method over radiation therapy. For differential indication of the multiple surgical treatment modalities prognostic scores are available to assist individual decision making. Indications for surgery include survival prognosis of minimum 3 months, intractable pain, progress of myelon compression and/or neurological deficits under radiochemotherapy, spinal instability and necessity for histological diagnosis. Resulting quality of life depends on efficient decompression of the spinal cord and restoration of spinal stability. To achieve these ultimate goals there are different anterior and posterior approaches, instrumentations and vertebral body replacement implants available. Preoperative embolization should be performed in hypervascular tumors, e.g., renal cell cancer. Vertebro-/Kyphoplasty as a percutaneous intervention should be considered for painful multisegmental disease and symptomatic osteolysis without epidural tumor compression to reach analgesia and stability. A multidisciplinary approach in patient selection, decision making and management is an essential precondition for complication avoidance and acceptable quality of life.