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Van den Brande R, Van den Kieboom M, Peeters M, Billiet C, Van de Kelft E. Remineralization of lytic spinal metastases after radiation therapy - A retrospective cohort study comparing conventional external beam radiation therapy with stereotactic ablative body radiation. Clin Transl Radiat Oncol 2024; 48:100805. [PMID: 38988807 PMCID: PMC11231653 DOI: 10.1016/j.ctro.2024.100805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 06/06/2024] [Accepted: 06/08/2024] [Indexed: 07/12/2024] Open
Abstract
Introduction Osteolytic spinal metastases (SM) have a higher risk of fracture. In this study we aim to confirm the remineralization of lytic SM after radiation therapy. Secondary the influence of SBRT compared to cEBRT and tumor type will be analyzed. Methods A retrospective cohort study was performed. Results 87 patients, 100 SM were included. 29 received SBRT, 71 cEBRT. Most common primary tumors were breast (35 %), lung (26 %) and renal (11 %). Both cEBRT and SBRT resulted in a significant increase of bone mineral density (BMD) (83.76 HU ± 5.72 → 241.41 HU ± 22.58 (p < 0.001) and 82.45 ± 9.13 → 179.38 ± 47.83p = 0.026). There was a significant increase in absolute difference of BMD between the SM and reference vertebrae (p < 0.001). There was no significant difference between SBRT and cEBRT. There was no increase of BMD in renal lytic SM after radiation therapy (pre-treatment: 85.96 HU ± 19.07; 3 m 92.00 HU ± 21.86 (p = 0.882); 6 m 92.06 HU ± 23.94 (p = 0.902); 9 m 70.44 HU ± 7.45 (p = 0.213); 12 m 98.08 HU ± 11.24 (p = 0.740)). In all other primary tumors, a significant increase of BMD after radiation therapy was demonstrated (p < 0,05). Conclusion We conclude that the BMD of lytic SM increases significantly after radiation therapy. Lytic SM of primary renal tumors are the exception; there is no significant remineralization of renal lytic SM after radiation therapy. There is no benefit of SBRT over cEBRT in this remineralization. These findings should be taken into account when deciding on surgery in the potentially unstable group defined by the spinal instability neoplastic score.
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Affiliation(s)
- Ruben Van den Brande
- University of Antwerp, Belgium
- Department of Neurosurgery, AZ KLINA, Brasschaat, Belgium
| | | | - Marc Peeters
- University of Antwerp, Belgium
- Department of Oncology, Antwerp University Hospital, Belgium
| | - Charlotte Billiet
- University of Antwerp, Belgium
- Department of Radiation Oncology, Iridium Netwerk, University of Antwerp, Belgium
| | - Erik Van de Kelft
- University of Antwerp, Belgium
- Department of Neurosurgery, Vitaz, Sint-Niklaas, Belgium
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Van den Brande R, Billiet C, Peeters M, Van de Kelft E. Spinal Metastases of the Vertebrae: Three Main Categories of Pain. Life (Basel) 2024; 14:988. [PMID: 39202730 PMCID: PMC11355794 DOI: 10.3390/life14080988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 08/02/2024] [Accepted: 08/06/2024] [Indexed: 09/03/2024] Open
Abstract
Oncologic back pain, infection, inflammation, and trauma are the only specific etiologies of chronic low back pain (CLBP) in contrast to most patients who have non-specific CLBP. In oncologic patients developing CLBP, it is critically important to perform further investigation to exclude spinal metastases (SM).The incidence of cancer is increasing, with 15.7-30% developing SM. In the case of symptomatic SM, we can distinguish three main categories: tumor pain; mechanical pain due to instability, with or without pathologic fractures; and metastatic epidural spinal cord compression (MESCC) or radicular compression. Treatment of SM-related pain is dependent on these categories and consists of symptomatic treatment, target therapy to the bone, radiotherapy, systemic oncologic treatment, and surgery. The care for SM is a multidisciplinary concern, with rapid evolutions in all specialties involved. It is of primordial importance to incorporate the knowledge of specialists in all participating disciplines, such as oncology, radiotherapy, and spinal surgery, to determine the adequate treatment to preserve ambulatory function and quality of life while limiting the burden of treatment if possible. Awareness of potential SM is the first and most important step in the treatment of SM-related pain. Early diagnosis and timely treatment could prevent further deterioration. In this review, we explore the pathophysiology and symptomatology of SM and the treatment options for SM-related pain: tumor pain; mechanical pain due to instability, with or without pathologic fractures; and MESCC or radicular compression.
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Affiliation(s)
- Ruben Van den Brande
- Faculty of Medicine and Health Sciences, University of Antwerp, 2000 Antwerpen, Belgium
- Department of Neurosurgery, AZ Klina, 2930 Brasschaat, Belgium
| | - Charlotte Billiet
- Faculty of Medicine and Health Sciences, University of Antwerp, 2000 Antwerpen, Belgium
- Department of Radiation Oncology, Iridium Netwerk, University of Antwerp, 2000 Antwerpen, Belgium
| | - Marc Peeters
- Faculty of Medicine and Health Sciences, University of Antwerp, 2000 Antwerpen, Belgium
- Department of Oncology, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Erik Van de Kelft
- Faculty of Medicine and Health Sciences, University of Antwerp, 2000 Antwerpen, Belgium
- Department of Neurosurgery, Vitaz, 9100 Sint-Niklaas, Belgium
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Hung SF, Tsai TT, Wang SF, Hsieh MK, Kao FC. Additional cement augmentation reduces cage subsidence and improves clinical outcomes in oblique lumbar interbody fusion combined with anterolateral screw fixation: A retrospective cohort study. Curr Probl Surg 2024; 61:101441. [PMID: 38360009 DOI: 10.1016/j.cpsurg.2024.101441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 02/17/2024]
Affiliation(s)
- Shih-Feng Hung
- Department of Orthopedic Surgery, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
| | - Tsung-Ting Tsai
- Department of Orthopaedic Surgery, Spine Section, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Sheng-Fen Wang
- Department of Anesthesiology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Kai Hsieh
- Department of Orthopaedic Surgery, Spine Section, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Fu-Cheng Kao
- Department of Orthopaedic Surgery, Spine Section, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan; Institute of Biomedical Engineering, National Tsing Hua University, Hsinchu, Taiwan.
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Newman WC, Larsen AG, Bilsky MH. The NOMS approach to metastatic tumors: Integrating new technologies to improve outcomes. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:487-499. [PMID: 37116749 DOI: 10.1016/j.recot.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 04/23/2023] [Indexed: 04/30/2023] Open
Abstract
Treatment paradigms for patients with spine metastases have evolved significantly over the past two decades. The most transformative change to these paradigms has been the integration of spinal stereotactic radiosurgery (sSRS). sSRS allows for the delivery of tumoricidal radiation doses with sparing of nearby organs at risk, particularly the spinal cord. Evidence supports the safety and efficacy of radiosurgery as it currently offers durable local tumor control with low complication rates even for tumors previously considered radioresistant to conventional external beam radiation therapy. The role for surgical intervention remains consistent, but a trend has been observed toward less aggressive, often minimally invasive techniques. Using modern technologies and improved instrumentation, surgical outcomes continue to improve with reduced morbidity. Additionally, targeted agents such as biologics and checkpoint inhibitors have revolutionized cancer care by improving both local control and patient survival. These advances have brought forth a need for new prognostication tools and a more critical review of long-term outcomes. The complex nature of current treatment schemes necessitates a multidisciplinary approach including surgeons, medical oncologists, radiation oncologists, interventionalists and pain specialists. This review recapitulates the current state-of-the-art, evidence-based data on the treatment of spinal metastases and integrates these data into a decision framework, NOMS, which is based on four sentinel pillars of decision making in metastatic spine tumors: Neurological status, Oncologic tumor behavior, Mechanical stability, and Systemic disease burden and medical co-morbidities.
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Affiliation(s)
- W C Newman
- Memorial Sloan Kettering Cancer Center, India
| | - A G Larsen
- Memorial Sloan Kettering Cancer Center, India; Weill Medical College of Cornell University, India
| | - M H Bilsky
- Memorial Sloan Kettering Cancer Center, India; Weill Medical College of Cornell University, India.
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Newman WC, Larsen AG, Bilsky MH. The NOMS approach to metastatic tumors: Integrating new technologies to improve outcomes. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:S487-S499. [PMID: 37562765 DOI: 10.1016/j.recot.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 04/23/2023] [Indexed: 08/12/2023] Open
Abstract
Treatment paradigms for patients with spine metastases have evolved significantly over the past two decades. The most transformative change to these paradigms has been the integration of spinal stereotactic radiosurgery (sSRS). sSRS allows for the delivery of tumoricidal radiation doses with sparing of nearby organs at risk, particularly the spinal cord. Evidence supports the safety and efficacy of radiosurgery as it currently offers durable local tumor control with low complication rates even for tumors previously considered radioresistant to conventional external beam radiation therapy. The role for surgical intervention remains consistent, but a trend has been observed toward less aggressive, often minimally invasive techniques. Using modern technologies and improved instrumentation, surgical outcomes continue to improve with reduced morbidity. Additionally, targeted agents such as biologics and checkpoint inhibitors have revolutionized cancer care by improving both local control and patient survival. These advances have brought forth a need for new prognostication tools and a more critical review of long-term outcomes. The complex nature of current treatment schemes necessitates a multidisciplinary approach including surgeons, medical oncologists, radiation oncologists, interventionalists and pain specialists. This review recapitulates the current state-of-the-art, evidence-based data on the treatment of spinal metastases and integrates these data into a decision framework, NOMS, which is based on four sentinel pillars of decision making in metastatic spine tumors: neurological status, Oocologic tumor behavior, mechanical stability and systemic disease burden and medical co-morbidities.
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Affiliation(s)
- W C Newman
- Memorial Sloan Kettering Cancer Center, Chennai, Tamil Nadu, India
| | - A G Larsen
- Memorial Sloan Kettering Cancer Center, Chennai, Tamil Nadu, India; Weill Medical College of Cornell University, India
| | - M H Bilsky
- Memorial Sloan Kettering Cancer Center, Chennai, Tamil Nadu, India; Weill Medical College of Cornell University, India.
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Borrelli S, Putame G, Audenino AL, Bignardi C, Ferro A, Marone S, Terzini M. Cross-link augmentation enhances CFR-PEEK short fixation in lumbar metastasis stabilization. Front Bioeng Biotechnol 2023; 11:1114711. [PMID: 36937770 PMCID: PMC10020173 DOI: 10.3389/fbioe.2023.1114711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/20/2023] [Indexed: 03/06/2023] Open
Abstract
Introduction: Spinal stability plays a crucial role in the success of the surgical treatment of lumbar vertebral metastasis and, in current practice, less invasive approaches such as short constructs have been considered. Concurrently, carbon fiber-reinforced (CFR) poly-ether-ether-ketone (PEEK) fixation devices are expanding in oncologic spinal surgery thanks to their radiotransparency and valid mechanical properties. This study attempts to provide an exhaustive biomechanical comparison of different CFR-PEEK surgical stabilizations through a highly reproducible experimental setup. Methods: A Sawbones biomimetic phantom (T12-S1) was tested in flexion, extension, lateral bending, and axial rotation. An hemisome lesion on L3 vertebral body was mimicked and different pedicle screw posterior fixations were realized with implants from CarboFix Orthopedics Ltd: a long construct involving two spinal levels above and below the lesion, and a short construct involving only the levels adjacent to L3, with and without the addition of a transverse rod-rod cross-link; to provide additional insights on its long-term applicability, the event of a pedicle screw loosening was also accounted. Results: Short construct reduced the overloading onset caused by long stabilization. Particularly, the segmental motion contribution less deviated from the physiologic pattern and also the long-chain stiffness was reduced with respect to the prevalent long construct. The use of the cross-link enhanced the short stabilization by making it significantly stiffer in lateral bending and axial rotation, and by limiting mobiliza-tion in case of pedicle screw loosening. Discussion: The present study proved in vitro the biomechanical benefits of cross-link augmentation in short CFR-PEEK fixation, demonstrating it to be a potential alternative to standard long fixation in the surgical management of lumbar metastasis.
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Affiliation(s)
- Simone Borrelli
- PolitoMed Lab, Politecnico di Torino, Turin, Italy
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
- *Correspondence: Simone Borrelli,
| | - Giovanni Putame
- PolitoMed Lab, Politecnico di Torino, Turin, Italy
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | - Alberto L. Audenino
- PolitoMed Lab, Politecnico di Torino, Turin, Italy
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | - Cristina Bignardi
- PolitoMed Lab, Politecnico di Torino, Turin, Italy
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | - Andrea Ferro
- Oncologic Orthopaedic Surgery Division, CTO Hospital—Città Della Salute e Della Scienza di Torino, Turin, Italy
| | - Stefano Marone
- Oncologic Orthopaedic Surgery Division, CTO Hospital—Città Della Salute e Della Scienza di Torino, Turin, Italy
| | - Mara Terzini
- PolitoMed Lab, Politecnico di Torino, Turin, Italy
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
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Newman WC, Bilsky MH. Fifty-year history of the evolution of spinal metastatic disease management. J Surg Oncol 2022; 126:913-920. [PMID: 36087077 PMCID: PMC11268045 DOI: 10.1002/jso.27028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/04/2022] [Indexed: 11/07/2022]
Abstract
Spine metastases are a significant source of morbidity in oncology. Treatment of these spine metastases largely remains palliative, but advances over the past 50 years have improved the effectiveness of interventions for preserving functional status and obtaining local control while minimizing morbidity. While the field began with conventional external beam radiation as the primary treatment modality, a series of paradigm shifts and technological advances in the 2000s led to a change in treatment patterns. These advances allowed for an increased role of surgical decompression of neural elements, a shift in the stereotactic capabilities of radiation oncologists, and an improved understanding of the radiobiology of metastatic disease. The result was improved local control while minimizing treatment morbidity. These advances fit within the larger framework of metastatic spine tumor management known as the Neurologic, Oncologic, Mechanical, and Systemic disease decision framework. This dynamic framework takes into account the neurological function of the patient, the radiobiology of their tumor, their degree of mechanical instability, and their systemic disease control and treatment options to help determine appropriate interventions based on the individual patient. Herein, we describe the 50-year evolution of metastatic spine tumor management and the impact of various advances on the field.
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Affiliation(s)
- W Christopher Newman
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mark H Bilsky
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York, USA
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Amin AG, Barzilai O, Bilsky MH. CT-Based Image-Guided Navigation and the DaVinci Robot in Spine Oncology: Changing Surgical Paradigms. HSS J 2021; 17:294-301. [PMID: 34539270 PMCID: PMC8436350 DOI: 10.1177/15563316211032009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Anubhav G Amin
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ori Barzilai
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mark H Bilsky
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Neurological Surgery, Weill Cornell Medicine, New York, NY, USA
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Bilsky MH, Barzilai O. Editorial. Multiple myeloma presenting as an unknown primary disease: to operate or not to operate, that is the question. Neurosurg Focus 2021; 50:E3. [PMID: 33932933 DOI: 10.3171/2021.2.focus21108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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