En bloc spondylectomy for primary malignant fibrous histiocytoma of the thoracic spine with aortic involvement: case report

Interdisciplinary Surgical Treatments and Long-Term Outcomes of Lumbar Spinal Tumors With Retroperitoneal Involvements: A Retrospective Case Series Study

Purpose

Surgical treatments are technically challenging for lumbar spinal tumor (LST) with extensive retroperitoneal involvements. Our study aimed to report the experience and outcomes concerning interdisciplinary surgical collaborations in managing such LSTs.

Patients and Methods

Nine patients underwent interdisciplinary surgical treatments which were performed by specialists, namely, spinal, vascular, and urinary surgeries. Data on clinical characteristics were collected, and the Visual Analogue Scale (VAS) and the Japanese Orthopaedic Association Score (JOAS) were used in the evaluation before and after surgery. The postoperative complications and the long-term outcomes were reported as well.

Results

The interdisciplinary work included double J catheter indwelling (n = 9), nephrostomy (n = 5), replacement of the common iliac vein (n = 2), abdominal aorta repair (n = 3), and vital vessel repair (n = 8). The early-stage complications included complaints of moderate low back pain and slight implant shift (n = 1, 11.1%) and tardive ureterodialysis (n = 1, 11.1%). The 3- and 5-year disease-free survival rates were 76.2 ± 14.8 and 50.8 ± 23.0%, respectively, during the mean follow-up of 34.6 ± 17.9 months (range, 9.5–68.7). Besides this, more blood loss was associated with recurrent and metastatic tumor status (p = 0.043) and surgery time >5 h (p = 0.023). Remarkable pain relief and favorable quality of life were achieved based on the postoperative VAS (3.3 ± 0.9, p < 0.001) and JOAS (16.6 ± 0.5, p < 0.001).

Conclusions

The treatments of LSTs with wide-range retroperitoneal involvements require interdisciplinary surgical collaborations to lower the risks and improve the long-term outcomes. High-quality prospective cohort studies with large samples are warranted to establish general surgical protocols in managing LSTs with extensive retroperitoneal involvements.

Carbon ion radiotherapy for unresectable primary undifferentiated pleomorphic sarcoma of the 11th thoracic spine: a case report

Objective: Primary undifferentiated pleomorphic sarcoma (UPS) of the bone is rare. However, the common sites are the knee and proximal femur and humerus, while spinal involvement is rare. We report a case of primary UPS of the 11th thoracic vertebra, where corpectomy would have been difficult and extensive, treated with carbon ion radiotherapy.

Case report: A 76-year-old man presented with an osteolytic tumor of the 11th thoracic vertebra on plain computed tomography (CT). The spinal cord was compressed and displaced posteriorly by the tumor on magnetic resonance imaging (MRI), and extraosseous extension was observed. An incisional biopsy was performed, and primary UPS of the 11th thoracic vertebra was diagnosed pathologically. Total en bloc spondylectomy was considered to be challenging because of the extraosseous extension and the patient’s age; thus, carbon ion radiotherapy (70.4 GyE / 32 fraction) was performed. Denosumab (120 mg) was administered subcutaneously every four weeks. No adjuvant chemotherapy was administered. Four years post-treatment, imaging revealed a compression fracture of the 11th thoracic vertebra, but there was no recurrence.

Conclusion: Despite a poor prognosis and an aggressive course of UPS of the spine, the tumor continues to be controlled without local recurrence four years after carbon ion radiotherapy.

Function Preservation or Oncological Appropriateness in Spinal Bone Tumors?: A Case Series of Segmental Resection of the Spinal Canal Content (Spinal Amputation)

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To evaluate (1) if the segmental resection of the content of the spinal canal could provide an Enneking appropriate tumor-free margin for local control of primary bone tumors surrounding and invading the canal and (2) the safety profile of the segmental resection of the neurostructures.

SUMMARY OF BACKGROUND DATA

Treatment outcomes of primary malignant and benign aggressive bone tumors of the spine have been dramatically changed by the application of the musculoskeletal oncologic principles described by Enneking. However, the efficacy of spinal oncology surgery might be limited by unique features of spinal anatomy.

METHODS

Database search was conducted with the following inclusion criteria: en bloc resection, segmental inclusion of the spinal canal content in the surgical specimen, histologically proven diagnosis, minimum follow-up of 2 years. Exclusion criteria were piecemeal excision of the tumor (debulking) and diagnosis other than primary bone tumors (metastasis, or local extension of extraosseous tumors).

RESULTS

A consecutive cohort of eight patients (three men, five women) was available for review. Two patients died within 3 months from the surgery for systemic disease progression or sequelae of the surgery. En bloc resection with segmental spinal canal content inclusion was able to achieve local control of the disease in four out of remaining six cases (66.7%) at an average follow-up of 68.7 months (range 12-174 mo). Three patients in whom local control was achieved are free from disease at an average follow-up of 98.7 months (range 38-174), and one died for systemic disease progression (after 38 mo). Seven out of 8 patients (87.5%) experienced overall 16 complications.

CONCLUSION

En bloc resection including the spinal canal content (spinal amputation) to achieve a tumor-free margin might be considered to perform an Enneking appropriate treatment for motivated patients.

LEVEL OF EVIDENCE

4.

Palliative Care of Malignant Fibrous Histiocytoma of Spine with Cord Compression and Multiple Bone Metastases Treated by Multidisciplinary Therapy: Case Report

Malignant fibrous histiocytoma (MFH) of the spine is rare, with only a few dozen cases reported in the literature. A 60-year-old male was referred to us with symptoms of thoracic myelopathy. A solid tumor in the Th8 right costovertebral junction invading the spinal canal and compressing the spinal cord, and multiple bony metastases were discovered. Biopsy confirmed MFH. The thoracic spine tumor showed good response to irradiation followed by embolization and partial resection. The patient was followed until his death 22 months later. A good quality of life was sustained for more than 18 months. Despite a poor prognosis and an aggressive course of MFH of the spine, a good quality of life could be sustained for more than a year with palliative interventions.

Revision surgery for tumors of the thoracic and lumbar spine: causes, prevention, and treatment strategy

INTRODUCTION

Revision surgery in spine tumor surgery can offer peculiar challenges given the severity of the majority of these lesions and the complexity of surgical procedures that are required.

MATERIALS AND METHODS AND RESULTS

Based on literature review and on personal experience, surgical site infection, cerebrospinal fluid leakage, tumor recurrence and hardware failures are some of the possible causes of surgical revision in this set of patients.

CONCLUSIONS

The aim of this study is to evaluate the most frequent complications that can lead to revision in spine tumor patients, to provide suggestions on how to prevent these events and to offer reasonable strategies to properly plan and perform a revision surgery. These slides can be retrieved under Electronic Supplementary Material.

Spinal sarcomas and immunity: An undervalued relationship

Sarcomas, especially spine sarcomas, are rare yet debilitating and are underestimated types of cancer. Treatment options for spine sarcomas are limited to chemotherapy, radiotherapy and surgical intervention. Accumulating evidence suggests a complex course associated with the treatment of spine sarcomas as compared to other soft tissue sarcomas in the extremities since adjuvant therapy adds limited success to the oncological outcome. Likewise, the limitations of surgical interventions imposed by the proximity and high sensitivity of the spinal cord, leads to an increased recurrence and mortality rates associated with spine sarcomas. Finding novel treatment options to spine sarcomas as such is inevitable, necessitating a more thorough understanding of the different mechanisms of the underlying etiologies of these tumors. In this review, we discuss the most recent studies tackling the involvement of the immune system; a key player in the emergence of the different types of spine sarcomas and the promising immune-mediated targeted therapy that can be applied in these kind of rare cancers.

Prognostic Factors for Patients With Undifferentiated High Grade Pleomorphic Sarcoma of the Spine

STUDY DESIGN

Retrospective survival analysis of 44 undifferentiated high grade pleomorphic sarcoma (UPS) of the spine.

OBJECTIVE

To identify factors related to overall survival (OS) and help decision making in the treatment of undifferentiated high grade pleomorphic sarcoma of the spine.

SUMMARY OF BACKGROUND DATA

UPS is an aggressive malignant tumor rarely originating from the spine. Due to its scarcity, only a few studies had been reported to describe the clinical features, treatments, and outcomes of sporadic cases, devoid of evaluation on prognostic factors.

METHODS

Enrolled in this survival analysis were 44 patients who underwent surgery and adjuvant therapies from January 1999 to December 2015. Kaplan-Meier methods were applied to estimate the overall survival. A multivariate Cox algorithm was applied to recognize factors independently associated with overall survival.

RESULTS

Multivariate analysis suggested that age greater than or equal to 55 years (hazard ratio [HR], 3.923, P < 0.001), Eastern Cooperative Oncology Group (ECOG) score four (HR, 4.656, P < 0.001), and subtotal resection or piecemeal total resection (HR, 4.375, P < 0.001) were independently associated with poor overall survival.

CONCLUSION

We identified independent prognostic factors of UPS of the spine. Subtotal resection or piecemeal total resection, age more than or equal to 55 years and ECOG score four are factors adversely affecting overall survival of patients with UPS of the spine.

LEVEL OF EVIDENCE

4.

Treatment of spinal malignant fibrous histiocytoma, a case report and literature review

OBJECTIVE

To present a case of spinal malignant fibrous histiocytoma in the fourth lumbar vertebra that received treatment by an L4 spondylectomy and placement of intervertebral expander and posterior fixation.

CASE REPORT

A 47-year-old male patient with no relevant history presented with lumbar pain of 2 months' evolution. Treated conservatively, with slight improvement in pain, the patient persisted with low back pain irradiation to pelvic members, predominantly left-sided, accompanied by weakness and claudication. Clinically, he presented with paresthesias 3/5, hypoaesthesia L4, L5 and S1, predominantly left-sided. Lumbosacral computerized axial tomography evidence of an osteolytic lesion in the L4 body, predominantly left-sided, with invasion of the lumbar canal with poorly delimited margins; lumbosacral spine MRI showed hyperintense lesion in T2, heterogeneous, with irregular borders involving more than 60% of the vertebral body of L4 with invasion of the spinal canal causing compression to the roots. He was treated with an L4 spondylectomy and placement of intervertebral expander and posterior fixation.

CONCLUSION

Spondylectomy is an effective option for the treatment of spinal malignant fibrous histiocytoma that involves combined approaches. However the challenge is greater since it requires a knowledge of the great abdominal vessels and multidisciplinary intervention.