Quality of life in patients with malignant spinal cord compression: a systematic review

INTRODUCTION

Malignant spinal cord compression (MSCC) is an oncological emergency that may result in a devastating combination of malignancy and disability. Existing quality of life (QoL) questionnaires commonly used in MSCC literature (EORTC QLQ-C30, BM-22, Brief Pain Inventory, and Spine Oncology Study Group Outcomes) may not capture all the commonly reported symptoms and lack specificity to MSCC. The primary objective of this systematic review is to determine unmet patient needs and underreported QoL issues and compile a comprehensive list of QoL issues. The secondary objective of this review is to compile all existing QoL tools and questionnaires and determine whether any QoL issues are not addressed in the existing tools currently used in the literature.

METHODS

A literature search was conducted on Ovid MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases between 1946 and February 6, 2023, to compile all QoL issues and existing questionnaires used to assess QoL in patients with MSCC. All study designs were included given that they discussed QoL issues specific to patients with MSCC.

RESULTS

The results of this systematic review identified the most frequently discussed QoL issues in the literature studying MSCC. This included direct symptoms of MSCC such as back pain, paralysis, limb weakness/numbness, and urinary/bowel incontinence. Indirect symptoms coming from radiotherapy treatment such as dysphagia, painful swallowing, mouth pain, dry mouth, diarrhea, fatigue, and nausea/vomiting were also noted. Other symptoms resulting from corticosteroid treatment included difficulty sleeping, blurring of vision, weight gain, and mood disturbance. Patients also experienced psychosocial issues such as anxiety, depression, emotional distress, low self-esteem, concerns about dependence on others, concerns about getting home, and fear about their prognosis and future.

CONCLUSION

This review highlights the QoL issues specific to patients with MSCC and QoL tools capturing these issues. Relevance of QoL issues identified in this systematic review must be prospectively validated by patients and healthcare professionals with experience in treating MSCC.

More help than harm: surgery for metastatic spinal cord compression is associated with more favorable overall survival within a propensity score analysis

PURPOSE

Indication for surgical decompression in metastatic spinal cord compression (MSCC) is often based on prognostic scores such as the modified Bauer score (mBs), with favorable prognosis suggestive of surgery and poor prognosis of non-surgical management. This study aimed to clarify if (1) surgery may directly affect overall survival (OS) aside from short-term neurologic outcome, (2) explore whether selected patient subgroups with poor mBs might still benefit from surgery, and (3) gauge putative adverse effects of surgery on short-term oncologic outcomes.

METHODS

Single-center propensity score analyses with inverse-probability-of-treatment-weights (IPTW) of OS and short-term neurologic outcomes in MSCC patients treated with or without surgery between 2007 and 2020.

RESULTS

Among 398 patients with MSCC, 194 (49%) underwent surgery. During a median follow-up of 5.8 years, 355 patients (89%) died. MBs was the most important predictor for spine surgery (p < 0.0001) and the strongest predictor of favorable OS (p < 0.0001). Surgery was associated with improved OS after accounting for selection bias with the IPTW method (p = 0.021) and emerged as the strongest determinant of short-term neurological improvement (p < 0.0001). Exploratory analyses delineated a subgroup of patients with an mBs of 1 point who still benefited from surgery, and surgery did not result in a higher risk of short-term oncologic disease progression.

CONCLUSION

This propensity score analysis corroborates the concept that spine surgery for MSCC associates with more favorable neurological and OS outcomes. Selected patients with poor prognosis might also benefit from surgery, suggesting that even those with low mBs may be considered for this intervention.

Predictive factors for respiratory failure and in-hospital mortality after surgery for spinal metastasis

PURPOSE

Spinal metastasis surgeries carry substantial risk of complications. PRF is among complications that significantly increase mortality rate and length of hospital stay. The risk factor of PRF after spinal metastasis surgery has not been investigated. This study aims to identify the predictors of postoperative respiratory failure (PRF) and in-hospital death after spinal metastasis surgery.

METHODS

We retrospectively reviewed consecutive patients with spinal metastasis surgically treated between 2008 and 2018. PRF was defined as mechanical ventilator dependence > 48 h postoperatively (MVD) or unplanned postoperative intubation (UPI). Collected data include demographics, laboratory data, radiographic and operative data, and postoperative complications. Stepwise logistic regression analysis was used to determine predictors independently associated with PRFs and in-hospital death.

RESULTS

This study included 236 patients (average age 57 ± 14 years, 126 males). MVD and UPI occurred in 13 (5.5%) patients and 13 (5.5%) patients, respectively. During admission, 14 (5.9%) patients had died postoperatively. Multivariate logistic regression analysis revealed significant predictors of MVD included intraoperative blood loss > 2000 mL (odds ratio [OR] 12.28, 95% confidence interval [CI] 2.88-52.36), surgery involving cervical spine (OR 9.58, 95% CI 1.94-47.25), and ASA classification ≥ 4 (OR 6.59, 95% CI 1.85-23.42). The predictive factors of UPI included postoperative sepsis (OR 20.48, 95% CI 3.47-120.86), central nervous system (CNS) metastasis (OR 10.21, 95% CI 1.42-73.18), lung metastasis (OR 7.18, 95% CI 1.09-47.4), and postoperative pulmonary complications (OR 6.85, 95% CI 1.44-32.52). The predictive factors of in-hospital death included postoperative sepsis (OR 13.15, 95% CI 2.92-59.26), CNS metastasis (OR 10.55, 95% CI 1.54-72.05), and postoperative pulmonary complications (OR 9.87, 95% CI 2.35-41.45).

CONCLUSION

PRFs and in-hospital death are not uncommon after spinal metastasis surgery. Predictive factors for PRFs included preoperative comorbidities, intraoperative massive blood loss, and postoperative complications. Identification of risk factors may help guide therapeutic decision-making and patient counseling.

Multidisciplinary Approach to Spinal Metastases and Metastatic Spinal Cord Compression—A New Integrative Flowchart for Patient Management

Metastatic spine disease (MSD) and metastatic spinal cord compression (MSCC) are major causes of permanent neurological damage and long-term disability for cancer patients. The development of MSD is pathophysiologically framed by a cooperative interaction between general mechanisms of bone growth and specific mechanisms of spinal metastases (SM) expansion. SM most commonly affects the thoracic spine, even though multiple segments may be affected concomitantly. The great majority of SM are extradural, while intradural-extramedullary and intramedullary metastases are less frequently seen. The management of patients with SM is particularly complex and challenging, with multiple factors—such as the spinal stability status, primary tumor radio and chemosensitivity, cancer biological burden, patient performance status and comorbidities, and patient’s oncological prognosis—influencing the clinical decision-making process. Different frameworks were developed in order to systematize and support this process. A multidisciplinary, personalized approach, enriched by the expertise of each involved specialty, is crucial. We reviewed the most recent evidence and proposed an updated algorithmic approach to patients with MSD according to the clinical scenario of each patient. A flowchart-based approach offers an evidence-based management of MSD, providing a valuable clinical decision tool in a context of high uncertainty and quick-acting need.

Surgery in Acute Metastatic Spinal Cord Compression: Timing and Functional Outcome

Simple Summary

Spinal metastases affect an exceptionally high number of cancer patients and thereby represent a common challenge for healthcare providers. Patients may suffer from debilitating symptoms, including excruciating back pain, immobility and even neurological dysfunction. An exceptionally acute clinical presentation is caused by the compression of the spinal cord through growth of a spinal metastasis within the spinal canal, which may leave the patient with acute spinal cord injury in need of rapid surgical treatment. In clinical practice and science, no true timeframe has yet been defined within which these patients need to undergo surgery, although it is generally understood that their recovery and functional rehabilitation correlate with the time to surgery after symptom onset. In our study, we analyzed a surgically treated cohort of patients with acute spinal cord injury by metastatic compression to investigate the correlation of the timing of surgery with neurological recovery. We were able to identify a subgroup of patients with significantly improved recovery, in whom surgery was initiated within 16 h after admission. Complication rates were not significantly more frequent in this subgroup compared to patients operated on after 16 h. Based on these findings, we conclude that striving for surgery as early as feasible is a warranted strategy in patients with acute neurological deterioration due to metastatic spinal cord compression.

Abstract

Background: Patients with metastatic spinal cord compression (MSCC) may experience long-term functional impairment. It has been established that surgical decompression improves neurological outcomes, but the effect of early surgery remains uncertain. Our objective was to evaluate the impact of early versus late surgery for acute MSCC due to spinal metastases (SM). Methods: We retrospectively reviewed a consecutive cohort of all patients undergoing surgery for SMs at our institution. We determined the prevalence of acute MSCC; the time between acute neurological deterioration as well as between admission and surgery (standard procedure: decompression and instrumentation); and neurological impairment graded by the ASIA scale upon presentation and discharge. Results: We screened 693 patients with surgery for spinal metastasis; 140 patients (21.7%) had acute MSCC, defined as neurological impairment corresponding to ASIA grade D or lower, acquired within 72 h before admission. Non-MSCC patients had surgery for SM-related cauda equina syndrome, radiculopathy and/or spinal instability. Most common locations of the SM in acute MSCC were the thoracic (77.9%) and cervical (10.7%) spine. Per standard of care, acute MSCC patients underwent surgery including decompression and instrumentation, and the median time from admission to surgery was 16 h (interquartile range 10–22 h). Within the group of patients with acute MSCC, those who underwent early surgery (i.e., before the median 16 h) had a significantly higher rate of ASIA improvement by at least one grade at discharge (26.5%) compared to those who had late surgery after 16 h (10.1%; p = 0.024). Except for a significantly higher sepsis rate in the late surgery group, complication rates did not differ between the late and early surgery subgroups. Conclusions: We report data on the largest cohort of patients with MSCC to date. Early surgery is pivotal in acute MSCC, substantially increasing the chance for neurological improvement without increasing complication rates. We found no significant impact when surgery was performed later than 24 h after admission. These findings will provide the framework for a much-needed prospective study. Until then, the treatment strategy should entail the earliest possible surgical intervention.

The performance of frailty in predictive modeling of short-term outcomes in the surgical management of metastatic tumors to the spine

BACKGROUND CONTEXT

The concept of frailty has become increasingly recognized, and while patients with cancer are at increased risk for frailty, its influence on perioperative outcomes in metastatic spine tumors is uncertain. Furthermore, the impact of frailty can be confounded by comorbidities or metastatic disease burden.

PURPOSE

The purpose of this study was to evaluate the influence of frailty and comorbidities on adverse outcomes in the surgical management of metastatic spine disease.

STUDY DESIGN/SETTING

Retrospective analysis of a nationwide database to include patients undergoing spinal fusion for metastatic spine disease.

PATIENT SAMPLE

A total of 1,974 frail patients who received spinal fusion with spinal metastasis, and 1,975 propensity score matched non-frail patients.

OUTCOME MEASURES

Outcomes analyzed included mortality, complications, length of stay (LOS), nonroutine discharges and costs.

METHODS

A validated binary frailty index (Johns Hopkins Adjusted Clinical Groups) was used to identify frail and non-frail groups, and propensity score-matched analysis (including demographics, comorbidities, surgical and tumor characteristics) was performed. Sub-group analysis of levels involved was performed for cervical, thoracic, lumbar and junctional spine. Multivariable-regression techniques were used to develop predictive models for outcomes using frailty and the Elixhauser Comorbidity Index (ECI).

RESULTS

7,772 patients underwent spinal fusion with spinal metastasis, of which 1,974 (25.4%) patients were identified as frail. Following propensity score matching for frail (n=1,974) and not-frail (n=1,975) groups, frailty demonstrated significantly greater medical complications (OR=1.58; 95% CI 1.33-1.86), surgical complications (OR=1.46; 95% CI 1.15-1.85), LOS (OR=2.65; 95% CI 2.09-3.37), nonroutine discharges (OR=1.79; 95% CI 1.46-2.20) and costs (OR=1.68; 95% CI 1.32-2.14). Differences in mortality were only observed in subgroup analysis and were greater in frail junctional and lumbar spine subgroups. Models using ECI alone (AUC=0.636-0.788) demonstrated greater predictive ability compared to those using frailty alone (AUC=0.633-0.752). However, frailty combined with ECI improved the prediction of increased LOS (AUC=0.811), cost (AUC=0.768), medical complications (AUC=0.723) and nonroutine discharges (AUC=0.718). Predictive modeling of frailty in subgroups demonstrated the greatest performance for mortality (AUC=0.750) in the lumbar spine, otherwise performed similarly for LOS, costs, complications, and discharge across subgroups.

CONCLUSIONS

A high prevalence of frailty existed in the current patient cohort. Frailty contributed to worse short-term adverse outcomes and could be more influential in the lumbar and junctional spine due to higher risk of deconditioning in the postoperative period. Predictions for short term outcomes can be improved by adding frailty to comorbidity indices, suggesting a more comprehensive preoperative risk stratification should include frailty.

Radiomics biopsy signature for predicting survival in patients with spinal bone metastases (SBMs)

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Prediction of survival is crucial for guiding patient-tailored treatment.

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Radiomics can be described as the next era of possibilities in precision medicine.

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Radiomics model had an inferior performance with no added predictive power to the clinical predictive model.

Study design

Retrospective analysis of a registered cohort of patients treated and irradiated for metastases in the spinal column in a single institute.

Objective

This is the first study to develop and internally validate radiomics features for predicting six-month survival probability for patients with spinal bone metastases (SBM).

Background data

Extracted radiomics features from routine clinical CT images can be used to identify textural and intensity-based features unperceivable to human observers and associate them with a patient survival probability or disease progression.

Methods

A study was conducted on 250 patients treated for metastases in the spinal column irradiated for the first time between 2014 and 2016, at the MAASTRO clinic in Maastricht, the Netherlands. The first 150 available patients were used to develop the model and the subsequent 100 patient were considered as a test set for the model. A bootstrap (B = 400) stepwise model selection, which combines both the forward and backward variable elimination procedure, was used to select the most useful predictive features from the training data based on the Akaike information criterion (AIC). The stepwise selection procedure was applied to the 400 bootstrap samples, and the results were plotted as a histogram to visualize how often each variable was selected. Only variables selected more than 90 % of the time over the bootstrap runs were used to build the final model.

A prognostic index (PI) called radiomics score (radscore) and clinical score (clinscore) was calculated for each patient. The prognostic index was not scaled, the original values were used which can be extracted from the model directly or calculated as a linear combination of the variables in the model multiplied by the respective beta value for each patient.

Results

The clinical model had a good discrimination power. The radiomics model, on the other hand, had an inferior performance with no added predictive power to the clinical model. The internal imaging characteristics do not seem to have a value in the prediction of survival. However, the Shape features were excluded from further analyses in our study since all biopsies had a standard shape hence no variability.

Non-fusion palliative spine surgery without reconstruction is safe and effective in spinal metastasis patients: retrospective study

Considering the shorter life expectancy and poorer prognosis of metastatic epidural spinal cord compression patients, anterior reconstruction and fusion may be unnecessary. This study aimed to investigate the outcomes of palliative surgery for metastatic epidural spinal cord compression with neurological deficit among patients who underwent posterior decompression and instrumentation without fusion or anterior reconstruction. This single-center retrospective review included all patients aged > 18 years with thoracic or lumbar spinal metastasis who were surgically treated for metastatic spinal cord compression without fusion or anterior reconstruction at the Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand during July 2015 to December 2017. Data from preoperation to the 1-year follow-up, including demographic and clinical data, Frankel classification, pain scores, complication, revision surgery, health-related quality-of-life scores, and survival data, were collected and analyzed. A total of 30 patients were included. The mean age was 59.83 ± 11.73 years, and 20 (66.7%) patients were female. The mean operative time was 208.17 ± 58.41 min. At least one Frankel grade improvement was reported in 53.33% of patients. The pain visual analog scale, the EuroQOL five-dimension five-level utility score, and the Oswestry Disability Index were all significantly improved at a minimum of 3 months after surgery. No intraoperative mortality or instrument-related complication was reported. The mean survival duration was 11.4 ± 8.97 months. Palliative non-fusion surgery without anterior reconstruction may be considered as a preferable choice for treating spinal metastasis patients with spinal cord compression with neurological deficits.

Evaluating ambulatory function as an outcome following treatment for spinal metastases: a systematic review

BACKGROUND CONTEXT

Studies regarding treatment of spinal metastases are critical to evidence-based decision-making. However, variation exists in how a key outcome, ambulatory function, is assessed.

PURPOSE

To characterize the sources and tools investigators have used to evaluate ambulatory function as an outcome following treatment of spinal metastases. We also sought to understand the ways ambulatory function has been conceptualized in prior studies.

STUDY DESIGN

Systematic review of the literature.

PATIENT SAMPLE

We identified 44 published studies for inclusion. Samples within these investigations ranged from 20 to 2,096 subjects.

OUTCOME MEASURES

We describe the methods investigators have used to evaluate ambulatory function following treatment for spinal metastases.

METHODS

We conducted a systematic review through PubMed, Scopus and Web of Science following PRISMA guidelines. We included studies that consisted of adult patients receiving operative or non-operative treatment for spinal metastases. We also required that study investigators specified post-treatment ambulatory function as an outcome. We recorded year of publication, study design, types of spinal metastases included in the study, treatments employed, and sample size. We also described the source (medical record, study-specific observer and/or provider, patient and/or participant), tool (standardized measure, quantitative, qualitative) and concept (eg, ambulatory vs. non-ambulatory; independent ambulation vs. ambulatory with assistance vs. non-ambulatory) used to assess ambulatory function.

RESULTS

We found the plurality of studies relied on medical record documentation as their source. Amongst prospective studies, only a minority used a quantitative measure (eg, prespecified degree of walking ability) to assess ambulatory function. Most studies conceptualized ambulatory function as a dichotomized outcome, typically ambulatory versus non-ambulatory or a similar equivalent.

CONCLUSIONS

Wide variation exists in how ambulatory function is defined in studies involving patients with spinal metastases. We suggest several improvements that will allow a more robust assessment of the quality and quantity of ambulatory function among patients treated for spinal metastases.

Performance assessment of the metastatic spinal tumor frailty index using machine learning algorithms: limitations and future directions

OBJECTIVE

Frailty is recognized as an important consideration in patients with cancer who are undergoing therapies, including spine surgery. The definition of frailty in the context of spinal metastases is unclear, and few have studied such markers and their association with postoperative outcomes and survival. Using national databases, the metastatic spinal tumor frailty index (MSTFI) was developed as a tool to predict outcomes in this specific patient population and has not been tested with external data. The purpose of this study was to test the performance of the MSTFI with institutional data and determine whether machine learning methods could better identify measures of frailty as predictors of outcomes.

METHODS

Electronic health record data from 479 adult patients admitted to the Massachusetts General Hospital for metastatic spinal tumor surgery from 2010 to 2019 formed a validation cohort for the MSTFI to predict major complications, in-hospital mortality, and length of stay (LOS). The 9 parameters of the MSTFI were modeled in 3 machine learning algorithms (lasso regularization logistic regression, random forest, and gradient-boosted decision tree) to assess clinical outcome prediction and determine variable importance. Prediction performance of the models was measured by computing areas under the receiver operating characteristic curve (AUROCs), calibration, and confusion matrix metrics (positive predictive value, sensitivity, and specificity) and was subjected to internal bootstrap validation.

RESULTS

Of 479 patients (median age 64 years [IQR 55-71 years]; 58.7% male), 28.4% had complications after spine surgery. The in-hospital mortality rate was 1.9%, and the mean LOS was 7.8 days. The MSTFI demonstrated poor discrimination for predicting complications (AUROC 0.56, 95% CI 0.50-0.62) and in-hospital mortality (AUROC 0.69, 95% CI 0.54-0.85) in the validation cohort. For postoperative complications, machine learning approaches showed a greater advantage over the logistic regression model used to develop the MSTFI (AUROC 0.62, 95% CI 0.56-0.68 for random forest vs AUROC 0.56, 95% CI 0.50-0.62 for logistic regression). The random forest model had the highest positive predictive value (0.53, 95% CI 0.43-0.64) and the highest negative predictive value (0.77, 95% CI 0.72-0.81), with chronic lung disease, coagulopathy, anemia, and malnutrition identified as the most important predictors of postoperative complications.

CONCLUSIONS

This study highlights the challenges of defining and quantifying frailty in the metastatic spine tumor population. Further study is required to improve the determination of surgical frailty in this specific cohort.

Comprehensive surgical treatment strategy for spinal metastases

The management of patients with spinal metastases (SM) requires a multidisciplinary team of specialists involved in oncological care. Surgical management has evolved significantly over the recent years, which warrants reevaluation of its role in the oncological treatment concept. Any patient with a SM was screened for study inclusion. We report baseline characteristics, surgical procedures, complication rates, functional status and outcome of a large consecutive cohort undergoing surgical treatment according to an algorithm. 667 patients underwent 989 surgeries with a mean age of 65 years (min/max 20–94) between 2007 and 2018. The primary cancers mostly originated from the prostate (21.7%), breast (15.9%) and lung (10.0%). Surgical treatment consisted of dorsoventral stabilization in 69.5%, decompression without instrumentation in 12.5% and kyphoplasty in 18.0%. Overall survival reached 18.4 months (95% CI 9.8–26.9) and the median KPS increased by 10 within hospital stay. Surgical management of SMs should generally represent the first step of a conclusive treatment algorithm. The need to preserve long-term symptom control and biomechanical stability requires a surgical strategy currently not supported by level I evidence.

A Novel Nomogram for Survival Prediction of Patients with Spinal Metastasis From Prostate Cancer

STUDY DESIGN

A retrospective study of 84 patients with spinal metastasis from prostate cancer (SMPCa) was performed.

OBJECTIVE

The aim of this study was to predict the survival of patients with SMPCa by establishing an effective prognostic nomogram model, associating with the affecting factors and compare its efficacy with the existing scoring models.

SUMMARY OF BACKGROUND DATA

Prostate cancer (PCa) is the second most frequently malignant cancer causing death in men, and the spine is the most common site of bone metastatic burden. The aim of this study was to establish a prognostic nomogram for survival prediction of patients with SMPCa, explore associated factors, and compare the effectiveness of the new nomogram prediction model with the existing scoring systems.

METHODS

Included in this study were 84 SMPCa patients who were admitted in our spinal tumor center between 2006 and 2018. Their clinical data were retrospectively analyzed by univariate and multivariate analyses to identify independent variables that enabled to predict prognosis. A nomogram, named Changzheng Nomogram for Survival Prediction (CNSP), was established on the basis of preoperative independent variables, and then subjected to bootstrap re-samples for internal validation. The predictive accuracy and discriminative ability were measured by concordance index (C-index). Receiver-operating characteristic (ROC) analysis with the corresponding area under the ROC was used to estimate the prediction efficacy of CNSP and compare it with the four existing prognostic models Tomita, Tokuhashi, Bauer, and Crnalic.

RESULTS

A total of seven independent variables including Gleason score (P = 0.001), hormone refractory (P < 0.001), visceral metastasis (P < 0.001), lymphocyte to monocyte ratio (P = 0.009), prostate-specific antigen (P = 0.018), fPSA/tPSA (P = 0.029), Karnofsky Performance Status (P = 0.039) were identified after accurate analysis, and then entered the nomogram with the C-index of 0.87 (95% confidence interval, 0.84-0.90). The calibration curves for probability of 12-, 24-, and 36-month overall survival (OS) showed good consistency between the predictive risk and the actual risk. Compared with the previous prognostic models, the CNSP model was significantly more effective than the four existing prognostic models in predicting OS of the SMPCa patients (p < 0.05).

CONCLUSION

The overall performance of the CNSP model was satisfactory and could be used to estimate the survival outcome of individual patients more precisely and thus help clinicians design more specific and individualized therapeutic regimens.Level of Evidence: 4.

Spine metastasis in patients with prostate cancer: Survival prognosis assessment

BACKGROUND

Patients presenting spine metastasis (SpM) from prostate cancer (PC) form a heterogeneous population, through this study, we aimed to clarify and update their prognostic assessment.

METHODS

The patient data used in this study was obtained from a French national multicenter database of patients treated for PC with SpM between 2014 and 2017. A total of 72 patients and 365 SpM cases were diagnosed.

RESULTS

The median overall survival time for all patients following the event of SpM was 28.8 months. First, we identified three significant survival prognostic factors of PC patients with SpM: good Eastern Cooperative Oncology Group/World Health Organization personnel status (Status 0 hazard ratio [HR]: 0.031, 95% confidence interval [CI]: 0.008-0.127; p < .0001) or (Status 1 HR: 0.163, 95% CI: 0.068-0.393; p < .0001) and SpM radiotherapy (HR: 2.923, 95% CI: 1.059-8.069; p < .0001). Secondly, the presence of osteolytic lesions of the spine (vs. osteoblastic) was found to represent an independent prognosis factor for longer survival [HR: 0.424, 95% CI: 0.216-0.830; p = .01]. Other factors including the number of SpM, surgery, extraspinal metastasis, synchrone metastasis, metastasis-free survival, and SpM recurrence were not identified as being prognostically relevant to the survival of patients with PC.

CONCLUSION

Survival and our ability to estimate it in patients presenting PC with SpM have improved significantly. Therefore, we advocate the relevance of updating SpM prognostic scoring algorithms by incorporating data regarding the timeline of PC as well as the presence of osteolytic SpM to conceive treatments that are adapted to each patient.

Clinical outcome of surgical management for symptomatic metastatic spinal cord compression from prostate cancer

BACKGROUND

Metastatic spinal cord compression (MSCC) from prostate cancer (PC) influences not only patients' prognosis but also their quality of life. However, little is known about the clinical outcome of surgery for MSCC from PC. We evaluated both the oncological and functional outcomes of decompression and reconstruction surgery for patients with symptomatic MSCC from PC.

METHODS

We assessed 19 patients who underwent decompression and reconstruction surgery for symptomatic MSCC from PC. Of these 19 patients, 8 had metastatic hormone-naïve PC (mHNPC) and 11 had metastatic castration-resistant PC (mCRPC).

RESULTS

The median age of the patients with mHNPC and mCRPC was 72 and 65 years, respectively. The median prostate-specific antigen level at the time of diagnosis of MSCC in patients with mHNPC and mCRPC was 910 and 67 ng/mL, respectively. Although two of eight patients (25.0%) with mHNPC were ambulatory preoperatively, six patients (75.0%) were ambulatory postoperatively. Among 11 patients with mCRPC, only 3 (27.3%) were ambulatory preoperatively, while 6 (54.5%) were ambulatory postoperatively. The median postoperative overall survival among patients with mHNPC and mCRPC were not reached and 8 months, respectively.

CONCLUSIONS

Decompression and reconstruction surgery for symptomatic MSCC from PC might contribute to a favorable functional outcome among men with mHNPC and mCRPC. However, its role in improving the oncological outcome remains unclear. The treatment strategy should be chosen by shared decision-making among patients, urologists, radiation oncologists, and orthopedic surgeons.

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

Background

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

Methods

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

Results

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

Conclusions

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

Level of evidence

I Meta-analysis.

Visceral Metastasis: A Prognostic Factor of Survival in Patients with Spinal Metastases

Objective

To characterize the visceral metastasis as a predictive tool for the survival of patients with spinal metastases through an exploratory meta‐analysis.

Methods

Two investigators independently searched PubMed and Embase databases for eligible studies from 2000–2016. The effect estimates for the hazard ratio (HR) or risk ratio (RR) and 95% confidence interval (CI) were collected and pooled with a random‐ or fixed‐effect model.

Results

In total, 18 eligible studies were retrieved with 5468 participants from nine countries. The overall pooled effect size for HR and RR was 1.50 and 3.79, respectively, which was proved to be statistically significant. In the subgroup of prostate cancer (PCa) and non‐small cell lung cancer (NSCLC), statistical significance and marginal statistical significance was presented for the pooled HR (HR = 1.76, 95% CI 1.35–2.29) and (RR = 1.56, 95% CI 0.99–2.48), respectively. However, in the subgroup of thyroid cancer, breast cancer, and renal cancer, statistical significance was not achieved (HR = 1.17, 95% CI 0.75–1.83, Z = 0.70, P = 0.486). The results did not show any evidence of publication bias.

Conclusions

This study demonstrated that visceral metastasis was a significant prognostic factor in patients with spinal metastases as a whole. Interestingly, the onset of visceral metastases differentially impacted the survival in different primary tumors. Therefore, the prognostic value of visceral metastasis might be related to the type of primary tumor.

Surgical Decompression of High-Grade Spinal Cord Compression from Hormone Refractory Metastatic Prostate Cancer

BACKGROUND

Spine and nonspine skeletal metastases occur in more than 80% of patients with prostate cancer.

OBJECTIVE

To examine the characteristics of the patient population undergoing surgery for the treatment of prostate cancer metastatic to the spine.

METHODS

A retrospective chart review was performed on all patients treated at our institution from June 1993 to August 2014 for surgical management of metastatic spine disease from prostate cancer.

RESULTS

During the study period, 139 patients with 157 surgical lesions underwent surgery for metastatic spine disease. Decompression for high-grade epidural spinal cord compression was required for 126 patients with 143 lesions. Preoperatively, 69% had a motor deficit and 21% were nonambulatory, with 32% due to motor weakness. At surgery, 87% of patients had hormone-refractory prostate cancer (HRPC) and 61% failed prior radiation. Median overall survival for HRPC patients was 6.6 mo (95% confidence interval [CI]: 5.6-8.6) while the median overall survival for hormone-sensitive patients was 16.3 mo (95% CI: 4.0-26.6).

CONCLUSION

The majority of patients undergoing surgery for prostate cancer metastases to the spine were refractory to hormone therapy, indicating that patients with hormone-sensitive prostate cancer are unlikely to develop symptomatic spinal cord compression or spinal instability. A significant number of HRPC patients presented with neurological deficits attributable to spinal cord compression. Vigilant monitoring for the development of signs and symptoms of epidural spinal cord compression and spinal instability in hormone-refractory patients is recommended. Surgical decision making may be affected by the much shorter postoperative survival for HRPC patients as compared to patients with hormone-sensitive cancer.

Clinical significance of traditional clinical parameters and inflammatory biomarkers for the prognosis of patients with spinal chondrosarcoma: a retrospective study of 150 patients in a single center

BACKGROUND

To investigate the clinical significance of five inflammatory biomarkers and conventional clinical parameters in prognostic prediction of spinal chondrosarcoma.

METHODS

Univariate and multivariate analyses were performed to investigate independent prognostic factors for recurrence and death of patients with spinal chondrosarcoma. Disease-free survival (DFS) and overall survival (OS) were estimated by Kaplan-Meier curve, and differences were analyzed by log-rank test. The optimal cutoff values for NLR, PLR, LMR, and CAR were determined by X-tile program.

RESULTS

The optimal cutoff value for NLR, PLR, LMR, AGR, and CAR was 2.7, 200, 3.0, 1.5, and 0.2, respectively. Of the 150 patients included, recurrence was detected in 105 patients, and death occurred in 78 patients. Multivariate analysis indicated that Tomita I-III, total resection, and CAR < 0.2 were significantly associated with longer DFS. Meanwhile, preoperative Frankel score D-E, total resection, and CAR < 0.2 were favorable prognostic factors for OS. Subtype analysis showed that only total resection was an independent prognostic factor for DFS of recurrent spinal chondrosarcoma.

CONCLUSION

Total resection could significantly reduce the recurrence rate of spinal chondrosarcoma and improve OS of chondrosarcoma patients. Tomita classification I-III was a favorable factor for DFS, and preoperative Frankel score A-C was an adverse prognostic factor for OS. CAR was the most robust prognostic indicator with a discriminatory ability as compared with other inflammatory indicators. These slides can be retrieved under Electronic Supplementary Material.

Relationship Between Visceral Metastases and Survival in Patients with Metastasis-related Spinal Cord Compression

OBJECTIVE

To investigate whether visceral metastases have a significant impact on survival in patients with metastasis-related spinal cord compression (MSCC), and to determine the difference in prognosis between patients with and without visceral metastases.

METHODS

Three institutional databases were searched to identify all patients who had undergone spinal surgery for spinal metastases between March 2002 and June 2010. Data on patient characteristics including pre- and post-operative medical conditions, were collected from medical records or by telephone follow-up. Survival data were obtained either from medical records or by searching a governmental cancer registry.

RESULTS

The mean age of study patients was 59.6 ± 10.5 years (range, 18-84 years), of whom 102 were male and 67 female. The median and mean postoperative survival times were 7.0 ± 0.5 (95% CI 6.0-8.0) months and 12.6 ± 1.2 (95% CI 10.1-15.0) months, respectively, in all patients, being 5.0 ± 0.5 (95% CI 4.0-6.0) months and 10.8 ± 2.4 (95% CI 6.1-15.5) months, respectively, for patients with visceral metastases and 7.0 ± 0.8 (95% CI 5.4-8.6) months and 13.0 ± 1.4 (95%CI 10.3-15.6) months, respectively, for patients without visceral metastases (P = 0.87). These survival times did not differ significantly between groups. Multivariate Cox proportional hazard regressions showed that visceral metastases had no statistically significant association with survival (P = 0.277), whereas rate of growth of primary tumor (P = 0.003), preoperative Karnofsky performance status (KPS) (P < 0.001), change in KPS (P < 0.001), and Frankel grade (P = 0.091) were independent prognostic factors in the whole cohort (P = 0.005). Changes in KPS (P = 0.001) and major complications (P = 0.003) were significantly associated with survival in patients with visceral metastases, whereas rate of growth of primary tumor (P = 0.016), change in KPS (P = 0.001), and preoperative KPS (P < 0.001) were significantly associated with survival in patients without visceral metastases.

CONCLUSIONS

Visceral metastases do not appear to predict the prognosis of patients with MSCC; thus, more aggressive surgery should be considered in patients with MSCC who have visceral metastases. Additionally, prognostic factors differ according to visceral metastases status in these patients.

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

Background

Cancer patients’ survival time has obviously improved, with the development of systemic treatment techniques. However, the probability of metastases to the vertebrae has also been increased which makes some adverse effects on patients’ quality of life. The prediction of survival plays a key role in choosing therapeutic modality, and Tokuhashi Score was established as one of the most commonly used predictive systems for spinal metastases. Thus, this study was conducted to identify the prognostic effect of factors involved in revised Tokuhashi Score (RTS).

Methods

Two investigators independently retrieved relevant literature on platforms of PubMed, Embase and Cochrane Library. We identified eligible studies through title/abstract and full-text perusing. Data was extracted including general information of studies, participants’ characteristics, therapeutic modality, overall survival and prognostic effect of factors. Hazard ratio (HR) for each factor was synthesized if available through fixed- or random-effect models as appropriate.

Results

A total of 63 eligible studies with 10,411 participants were identified. Overall, cases with thyroid cancer had the highest survival rate, while the ones with non-small cell lung cancer and hepatocellular carcinoma lived for the shorted survival time. Performance status, bone metastasis, number of involved vertebrae, visceral metastasis, primary tumor and neurological status were regarded as significant predictors in 71.4, 40.0, 18.2, 63.4, 73.1 and 44.7% of the involved studies respectively. Thirty-eight articles were included in meta-analysis, and prognostic effects of five factors (apart from primary tumor) were analyzed. Factors were all proved to be significant except comparisons between KPS (Karnofsky Performance Status) 10–40 VS. 50–70 and single VS. multiple spinal metastases.

Conclusion

All factors of RTS were significant on prognosis predicting and should be considered when choosing therapeutic modality for spinal metastases. What’s more, we believe that more accurate prognosis may be obtained after removal of the cut-offs for KPS 10–40 VS. 50–70 and single VS. multiple involved vertebrae.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-5139-2) contains supplementary material, which is available to authorized users.

Surgical results and clinical risks of postoperative complications in patients with painful malignant spinal cord compression after decompressive surgery

Introduction

This study aims to analyze clinical outcome in patients with painful malignant spinal cord compression due to advanced cancers after the decompressive surgery and identify risk factors for postoperative complications in these patients. Furthermore, we created a scoring model to predict the risk of postoperative complications based on identified significant risk factors.

Methods

We retrospectively analyzed survival outcomes, pain outcomes, and postoperative complications of patients with painful malignant spinal cord compression who were surgically treated in our department. Identification of risk factors for postoperative complications was also performed, and significant factors according to the multiple logistic regression models were included in the scoring model.

Results

As a result, 105 patients were enrolled. The overall median survival time was 9.1 months (95% CI, 7.1–11.4 months). The mean worst pain score was 8.0 in a 24-hour period before surgery, while it decreased to 6.0, 5.0, 3.5, 3.3, and 3.6 (all P<0.01, when compared with baseline date) at 1 week, 1 month, 3, 6, and 12 months after surgery, respectively. Similar decreases were also observed in the average pain and the pain interference. Thirty-one complications occurred within 4 weeks after operation in 26 patients (24.8%, 26/105). Based on multiple logistic regression models, age (P=0.03), Karnofsky performance status (P<0.01), and Charlson Comorbidity Index (P=0.04) were significantly associated with postoperative complications and were included in the scoring model. Three risk groups were created based on the complication rates of each scoring points. The corresponding postoperative complication rates of the three groups were 7.7% in group A (0–3 points), 26.7% in group B (4–6 points), and 60.9% in group C (7–10 points), respectively (OR, 4.32, 95% CI: 2.24–8.31, P<0.01).

Conclusion

Decompressive surgery for painful malignant spinal cord compression was found to be useful for pain control with a tolerable rate of complications. We created a scoring model to predict the risk of postoperative complications in patients with painful malignant spinal cord compression after surgery. This scoring model may guide doctors to choose the appropriate care strategies to realize better pain management.

Systematic Review of the Outcomes of Surgical Treatment of Prostate Metastases to the Spine

STUDY DESIGN

Systematic review.

OBJECTIVE

Surgical decompression and reconstruction of symptomatic spinal metastases has improved the quality of life in cancer patients. However, most data has been collected on cohorts of patients with mixed tumor histopathology. We systematically reviewed the literature for prognostic factors specific to the surgical treatment of prostate metastases to the spine.

METHODS

A systemic review of the literature was conducted to answer the following questions: Question 1. Describe the survival and functional outcomes of surgery or vertebral augmentation for prostate metastases to the spine. Question 2. Determine whether overall tumor burden, Gleason score, preoperative functional markers, and hormonal naivety favor operative intervention. Question 3. Establish whether clinical outcomes vary with the evolution of operative techniques.

RESULTS

A total of 16 studies met the preset inclusion criteria. All included studies were retrospective series with a level of evidence of IV. Included studies consistently showed a large effect of hormone-naivety on overall survival. Additionally, studies consistently demonstrated an improvement in motor function and the ability to maintain/regain ambulation following surgery resulting in moderate strength of recommendation. All other parameters were of insufficient or low strength.

CONCLUSIONS

There is a dearth of literature regarding the surgical treatment of prostate metastases to the spine, which represents an opportunity for future research. Based on existing evidence, it appears that the surgical treatment of prostate metastases to the spine has consistently favorable results. While no consistent preoperative indicators favor nonoperative treatment, hormone-naivety and high Karnofsky performance scores have positive effects on survival and clinical outcomes.

Decompression surgery for spinal metastases: a systematic review

OBJECTIVE The aim of this study was to systematically review the literature on reported outcomes following decompression surgery for spinal metastases. METHODS The authors conducted MEDLINE, Scopus, and Web of Science database searches for studies reporting clinical outcomes and complications associated with decompression surgery for metastatic spinal tumors. Both retrospective and prospective studies were included. After meeting inclusion criteria, articles were categorized based on the following reported outcomes: survival, ambulation, surgical technique, neurological function, primary tumor histology, and miscellaneous outcomes. RESULTS Of the 4148 articles retrieved from databases, 36 met inclusion criteria. Of those included, 8 were prospective studies and 28 were retrospective studies. The year of publication ranged from 1992 to 2015. Study size ranged from 21 to 711 patients. Three studies found that good preoperative Karnofsky Performance Status (KPS ≥ 80%) was a significant predictor of survival. No study reported a significant effect of time-to-surgery following the onset of spinal cord compression symptoms on survival. Three studies reported improvement in neurological function following surgery. The most commonly cited complication was wound infection or dehiscence (22 studies). Eight studies reported that preoperative ambulatory or preoperative motor status was a significant predictor of postoperative ambulatory status. A wide variety of surgical techniques were reported: posterior decompression and stabilization, posterior decompression without stabilization, and posterior decompression with total or subtotal tumor resection. Although a wide range of functional scales were used to assess neurological outcomes, four studies used the American Spinal Injury Association (ASIA) Impairment Scale to assess neurological function. Four studies reported the effects of radiation therapy and local disease control for spinal metastases. Two studies reported that the type of treatment was not significantly associated with the rate of local control. The most commonly reported primary tumor types included lung cancer, prostate cancer, breast cancer, renal cancer, and gastrointestinal cancer. CONCLUSIONS This study reports a systematic review of the literature on decompression surgery for spinal metastases. The results of this study can help educate surgeons on the previously published predictors of outcomes following decompression surgery for metastatic spinal disease. However, the authors also identify significant gaps in the literature and the need for future studies investigating the optimal practice with regard to decompression surgery for spinal metastases.

Thirty-day readmission and reoperation after surgery for spinal tumors: a National Surgical Quality Improvement Program analysis

OBJECTIVE

The goal of this study was to use a large national registry to evaluate the 30-day cumulative incidence and predictors of adverse events, readmissions, and reoperations after surgery for primary and secondary spinal tumors.

METHODS

Data from adult patients who underwent surgery for spinal tumors (2011–2014) were extracted from the prospective National Surgical Quality Improvement Program (NSQIP) registry. Multivariable logistic regression was used to evaluate predictors of reoperation, readmission, and major complications (death, neurological, cardiopulmonary, venous thromboembolism [VTE], surgical site infection [SSI], and sepsis). Variables screened included patient age, sex, tumor location, American Society of Anesthesiologists (ASA) physical classification, preoperative functional status, comorbidities, preoperative laboratory values, case urgency, and operative time. Additional variables that were evaluated when analyzing readmission included complications during the surgical hospitalization, hospital length of stay (LOS), and discharge disposition.

RESULTS

Among the 2207 patients evaluated, 51.4% had extradural tumors, 36.4% had intradural extramedullary tumors, and 12.3% had intramedullary tumors. By spinal level, 20.7% were cervical lesions, 47.4% were thoracic lesions, 29.1% were lumbar lesions, and 2.8% were sacral lesions. Readmission occurred in 10.2% of patients at a median of 18 days (interquartile range [IQR] 12–23 days); the most common reasons for readmission were SSIs (23.7%), systemic infections (17.8%), VTE (12.7%), and CNS complications (11.9%). Predictors of readmission were comorbidities (dyspnea, hypertension, and anemia), disseminated cancer, preoperative steroid use, and an extended hospitalization. Reoperation occurred in 5.3% of patients at a median of 13 days (IQR 8–20 days) postoperatively and was associated with preoperative steroid use and ASA Class 4–5 designation. Major complications occurred in 14.4% of patients: the most common complications and their median time to occurrence were VTE (4.5%) at 9 days (IQR 4–19 days) postoperatively, SSIs (3.6%) at 18 days (IQR 14–25 days), and sepsis (2.9%) at 13 days (IQR 7–21 days). Predictors of major complications included dependent functional status, emergency case status, male sex, comorbidities (dyspnea, bleeding disorders, preoperative systemic inflammatory response syndrome, preoperative leukocytosis), and ASA Class 3–5 designation (p < 0.05). The median hospital LOS was 5 days (IQR 3–9 days), the 30-day mortality rate was 3.3%, and the median time to death was 20 days (IQR 12.5–26 days).

CONCLUSIONS

In this NSQIP analysis, 10.2% of patients undergoing surgery for spinal tumors were readmitted within 30 days, 5.3% underwent a reoperation, and 14.4% experienced a major complication. The most common complications were SSIs, systemic infections, and VTE, which often occurred late (after discharge from the surgical hospitalization). Patients were primarily readmitted for new complications that developed following discharge rather than exacerbation of complications from the surgical hospital stay. The strongest predictors of adverse events were comorbidities, preoperative steroid use, and higher ASA classification. These models can be used by surgeons to risk-stratify patients preoperatively and identify those who may benefit from increased surveillance following hospital discharge.

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

Background

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

Methods

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

Results

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

Conclusions

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

Survival and Clinical Outcomes in Surgically Treated Patients With Metastatic Epidural Spinal Cord Compression: Results of the Prospective Multicenter AOSpine Study

PURPOSE

Although surgery is used increasingly as a strategy to complement treatment with radiation and chemotherapy in patients with metastatic epidural spinal cord compression (MESCC), the impact of surgery on health-related quality of life (HRQoL) is not well established. We aimed to prospectively evaluate survival, neurologic, functional, and HRQoL outcomes in patients with MESCC who underwent surgical management.

PATIENTS AND METHODS

One hundred forty-two patients with a single symptomatic MESCC lesion who were treated surgically were enrolled onto a prospective North American multicenter study and were observed at least up to 12 months. Clinical data, including Brief Pain Inventory, ASIA (American Spinal Injury Association) impairment scale, SF-36 Short Form Health Survey, Oswestry Disability Index, and EuroQol 5 dimensions (EQ-5D) scores, were obtained preoperatively, and at 6 weeks and 3, 6, 9, and 12 months postoperatively.

RESULTS

Median survival time was 7.7 months. The 30-day and 12-month mortality rates were 9% and 62%, respectively. There was improvement at 6 months postoperatively for ambulatory status (McNemar test, P < .001), lower extremity and total motor scores (Wilcoxon signed rank test, P < .001), and at 6 weeks and 3, 6, and 12 months for Oswestry Disability Index, EQ-5D, and pain interference (paired t test, P < .013). Moreover, at 3 months after surgery, the ASIA impairment scale grade was improved (Stuart-Maxwell test P = .004). SF-36 scores improved postoperatively in six of eight scales. The incidence of wound complications was 10% and 2 patients required a second surgery (screw malposition and epidural hematoma).

CONCLUSION

Surgical intervention, as an adjunct to radiation and chemotherapy, provides immediate and sustained improvement in pain, neurologic, functional, and HRQoL outcomes, with acceptable risks in patients with a focal symptomatic MESCC lesion who have at least a 3 month survival prognosis.

Clinical features and prognostic factors of patients with chordoma in the spine: a retrospective analysis of 153 patients in a single center

BACKGROUND

Chordoma in the spine is relatively rare, and minimal information has been published in the literature regarding this subject. Moreover, there are controversies over prognostic factors of this disease.

METHODS

A retrospective analysis of chordoma in the spine was performed by survival analysis. Local relapse-free survival (LRFS) and overall survival (OS) were analyzed from the date of surgery to the date of local recurrence and death. The LRFS and OS rates were estimated using the Kaplan-Meier method to identify potential prognostic factors. Factors with P values ≤ .1 were subjected to multivariate analysis by Cox regression analysis. P values ≤ .05 were considered statistically significant.

RESULTS

A total of 153 patients with spinal chordoma were included in the study. The mean follow-up period was 72.0 months (range, 1-279 months). Local recurrence was detected in 51 cases after initial surgery in our center, while death occurred in 42 cases. The statistical analysis suggested that tumor location of C3-L5, dedifferentiated chordoma, preoperative Frankel scores A-C, and total spondylectomy were independent prognostic factors for LRFS. In addition, total en bloc spondylectomy and Karnofsky' performance status (KPS) ≥ 80% were favorable factors for OS.

CONCLUSIONS

Total spondylectomy, by either en bloc or piecemeal method, could significantly reduce LRFS for spinal chordoma. Location of C3-L5 is a favorable factor for LRFS, while dedifferentiated subtype and preoperative Frankel scores A-C are adverse prognostic factors. In addition, total en bloc spondylectomy and KPS ≥ 80% significantly improve overall survival of patients with spinal chordoma.

Surgical Management of Primary and Metastatic Spinal Tumors

Background

The axial skeleton is a common site for primary tumors and metastatic disease, with metastatic disease being much more common. Primary and metastatic spinal tumors have a diverse range of aggressiveness, ranging from benign lesions to highly infiltrative malignant tumors.

Methods

The authors reviewed the results of articles describing the treatment and outcomes of patients with metastatic disease or primary tumors of the spinal column.

Results

En bloc resection is the mainstay of treatment for malignant primary tumors of the spinal column. Intralesional resection is generally appropriate for benign primary tumors. Low-quality evidence supports the use of chemotherapy in select primary tumors; however, radiation therapy is often used for incompletely resected or unresectable lesions. Surgical considerations for the treatment of metastatic disease are more nuanced and require that the health care professional consider patient performance status and the pathology of the primary tumor.

Conclusions

The treatment of metastatic and primary tumors of the spinal column requires a multidisciplinary approach in order to offer patients the best opportunity for long-term survival.

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.

Prolonged survival following aggressive treatment for metastatic breast cancer in the spine

In 2007, members of our group reported a 21 month median survival for patients undergoing surgery for metastatic breast cancer in the spinal column. Cervical spine metastases were associated with decreased survival, Estrogen receptor positivity was associated with improved survival, and age and visceral metastases did not significantly impact survival. In the current study, we reassess these variables in the context of modern adjuvant therapies, and investigate the impact of the Spinal Instability Neoplastic Score (SINS). We report an observational cohort of 43 patients undergoing surgical resection for metastatic breast cancer of the spine treated at a single academic institution from June 2002 to August 2011. Patient medical records were reviewed in accordance with policies outlined by the University Institutional Review Board. Median overall survival following surgery for metastatic breast cancer in the spine was 26.8 months. 1 year overall survival was 66%. 5 year-overall survival was 4%. Age (p=0.12), preoperative functional status (p=0.17), location of metastasis (p=0.34), the presence of visceral metastases (p=0.68), and spinal instability (p=0.81) were not significant variables on survival analysis. Postoperative adjuvant therapy with a single modality (radiation or chemotherapy) was associated with a significantly lower median survival compared to dual therapy with chemotherapy and radiation (p=0.042). Patients that received radiation and chemotherapy after surgery were younger but demonstrated prolonged median survival versus single modality therapy. This data supports the concept that visceral metastases do not impact survival, however cervical spine lesions were not associated with decreased survival.