Solitary Plasmacytoma of the Vertebral Column. A Report of 15 Cases

Surgical management and prognostic factors of spinal metastatic tumors

Objective

This study aims to evaluate different prognostic factors after surgical management of metastatic spinal tumors regarding clinical condition, preoperative investigations, histopathological results, and surgical data.

Methods

Seventy patients diagnosed as metastatic spinal tumors with neurological deficits and/or unstable spine operated for spinal decompression with or without instrumental fixation according to Spinal Instability Neoplastic Score (SINS) at our institute during the period from May 2014 to October 2018 with follow-up at least 9 months.

Results

Lymphoma metastases were the commonest spinal metastases of 23% with significant p value = 0.001, males and ages above 50 years old were significantly affected. High vascularity and bone invasion were significant operative findings. Significant good prognostic factors for both survival and Klekampe score improvement were paretic patients, > 15 preoperative Klekampe score, early surgery, ≤ 3 vertebral affection, extradural tumor location, gross total resection, and metastatic tumors from multiple myeloma, thyroid gland, lymphoma, and prostatic gland.

Conclusion

Early surgeries aiming neural decompression and keeping spinal stability according to Spinal Instability Neoplastic Score for patients with spinal metastases are the main hope for better survival and neurological improvement.

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

INTRODUCTION

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

METHODS

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

CONCLUSIONS

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

Treatment of spinal epidural compression due to hematological malignancies: a single institution's retrospective experience

PURPOSE

To analyze the neurological and mechanical outcomes in 44 consecutive patients treated for a hematological malignancy with epidural localization to assess the place of surgery in the treatment of this pathology.

METHODS

Clinical records, CT and MRI scans of 44 patients with epidural localizations of multiple myeloma or lymphoma treated between 1990 and 2005 were analyzed retrospectively. Neurological status, epiduritis and osteolysis volumes, vertebral collapse, and spinal canal compromise were assessed. The neurological outcome was graded according to Frankel and the mechanical outcome was evaluated on the rate of vertebral collapse.

RESULTS

Surgery was performed in 11 patients (25 %) for neurological (n = 9) or mechanical (n = 2) reasons. In five cases, a concomitant biopsy was performed because the etiology of the epiduritis was unknown. Fifteen patients (34.1 %) presented with a neurological deficit secondary to an acute vertebral collapse (n = 4), an epiduritis (n = 7), or both (n = 4). Whatever the treatment (surgical or not), a complete recovery (Frankel E) occurred in 14/15 (93.3 %) after a mean delay of 12 weeks (range 2-24 weeks). During the follow-up, seven collapses occurred. We estimated that a threshold of 30 % of osteolysis was associated with a significant risk of vertebral collapse (P = 0.005).

CONCLUSIONS

Hematological malignancies with epidural localization must be treated first medically, even in patients with neurological symptoms. Surgery should be considered only in the cases of acute vertebral collapse, medical treatment failure, or to prevent acute collapse in patients with vertebral osteolysis of more than 30 %.

Surgical Management of Metastatic Spinal Tumors

Background

The spine is the most common site of skeletal metastases. The evolution of surgical methods, medical treatment, and radiation therapy has led to improved survival, functional status, and quality of life for patients with cancer. The role of surgery in the treatment of patients with spinal metastases has evolved over time.

Methods

A review of publications describing the role of open surgery and vertebroplasty was performed and the results are summarized.

Results

The treatment goals of spinal metastases include the preservation and restoration of neurologic function and spinal stability. Modern imaging modalities provide accurate methods of tumor diagnosis. A variety of approaches and stabilization techniques are available and should be tailored to the location of the tumor and systemic comorbidities.

Conclusions

As part of multidisciplinary treatment that includes radiation therapy and chemotherapy, surgery provides an effective method of restoration and preservation of neurologic function and spinal stability for patients with metastatic spinal tumors.

Solitary plasmacytoma of the thoracic vertebra presenting with sudden paraplegia and back pain: a pathologic case report

Solitary plasmacytoma (SPC) accounts for 5% of plasma cell neoplasm. SPC of the spine is relatively rare, and SPC presenting with sudden paraplegia is very rare. A 53 year-old woman was admitted to our hospital complaining of sudden severe paraplegia and back pain. Emergency MRI revealed a tumor of the thoracic vertebra no. 10 (Th10). Pressure fracture of the Th10 was also recognized. The tumor was not osteolytic and invasion was recognized around the Th10. The tumor directly compressed the spinal cord. An excision of the tumor was performed under the clinical diagnosis of metastatic carcinoma. Pathologtically, the tumor consisted of plasmacytoid atypical cells with hyperchromatic nuclei. Histochemically, the tumor cells showed pyroninophilia. Immunohistochemically, the tumor cells were positive for λ-light chain, but negative for cytokeratin, epithelial mermbrane antigen, vimentin, CD45, CD20, CD45RO, κ-light chain, α-heavy chain, λ-heavy chain, μ-heavy chain, δ-heavy chain, ε-heavy chain, IgA, IgG, IgM, synaptophysin, chromogranin, S100 protein, desmin, α-smooth muscle antigen, myoglobin, and p53 protein. The Ki-67 labeling was 73%. The author diagnosed the tumor as SPC with λ-light chain disease. After the diagnosis, whole body CT and MRI revealed no other tumors. Blood and serum test revealed no significant changes; no M-protein was recognized. However, voided urine test revealed λ-light chain protein. The patient underwent fixation operation of TH10, and received radiation (50 Gray) and chemotherapy. No recurrence or transformation into myeloma occurred at the present time 25 months after the first manifestation. The present study indicated that pathological examination is an only clue to the diagnosis of SPC of the vertebra bone.

Pathological fracture of the atlas secondary to plasmacytoma

Plasmacytoma of the atlas with pathological fracture has not been previously reported. A 72-year-old man was admitted to our clinic with a 5-month history of occipital headache. Neurologic examination revealed mild occipital neuralgia, difficulty with movements of the cranium, hyperactive deep tendon reflexes, but no Babinski sign. Magnetic resonance imaging (MRI) of the cervical spine showed a 1x2 cm well-circumscribed extradural mass, with lytic destruction and fracture of the lateral mass of C1. Preoperatively dynamic cervical radiographs showed no instability. Using a transcondylar approach, the tumor was removed, and posterolateral fixation and fusion (using iliac autograft) was performed. Biopsy was reported as plasmacytoma. The patient was pain-free with bony fusion 3 years after surgery. This paper presents a pathologic fracture of C1. Although the primary treatment of plasmacytoma is non-surgical, the need for tissue diagnosis in relevant areas may dictate an open biopsy procedure. Such cases may require a decompression and reconstruction procedure.

Vertebral tumors: surgical versus nonsurgical treatment

The treatment of spinal tumors represents a challenge to spine care professionals. Fortunately, the incidence of new cases of primary malignant bone tumors is lower compared with that of other tumors. In the United States approximately 2000 malignant bone tumors of 7000 new sarcomas are diagnosed each year. Of these, 4% to 20% (80-400 tumors) of bone tumors are spinal tumors. Metastatic tumors are the most frequent tumor of bone and the most frequent tumor of the spinal column regardless of the origin of the primary tumor. More than 90% of spinal tumors are metastatic. Thirty to seventy percent of patients who die from cancer have evidence of vertebral metastases visible on careful postmortem examination, with the potential that this number could reach 85% in patients with breast cancer. Less than 10% of patients with spinal tumors present with spinal instability requiring surgical treatment; this accounts for approximately 18,000 new cases yearly. We will focus on the most recent advances in nonsurgical and surgical treatment of vertebral tumors. In surgical treatment, the evaluation and selection of patients, indications and surgical strategies, open and minimally invasive techniques, outcomes and complications will be discussed.

LEVEL OF EVIDENCE

Level V (expert opinion). See the Guidelines for Authors for a complete description of the levels of evidence.

Spinal epidural involvement in haematological tumors: clinical features and therapeutic options

Haematological malignancies that may cause epidural spinal cord compression (SCC) include plasma cell dyscrasias, lymphomas and infrequently leukemias. Bone lesions are the major clinicopathologic manifestations in plasma cell dyscrasias but are evident in less than 30% of patients with SCC due to lymphomas. The incidence of SCC in solitary plasmacytomas is between 43 to 71%, in contrast to 7.4 to 16% in multiple myeloma where vertebral involvement is always present. The incidence of SCC in Hodgkin's disease and in non-Hodgkin's lymphomas is about 4 and 2.5% respectively. Spinal computed tomography, myelography and magnetic resonance imaging serve for establishing a definite diagnosis, assessment of tumor location within the spinal canal, delineation of the involved spinal levels, evaluation of spinal stability and for detection of extraosseous paravertebral extension. Treatment planning is based on the information obtained above, combined with clinical considerations. The primary modalities of therapy are radio- and chemotherapy. Surgery is reserved for those cases presenting with SCC when tissue diagnosis is unavailable, recurrence of SCC after previous irradiation and for spinal instability or compression of the neural elements by impinging bone fragments.