Diagnosis Of Spinal Metastasis Research Articles

Epidemiology, Pathogenesis, Clinical Presentation, and Diagnostic Approach

Spinal metastatis is a diagnostic and treatment challenge for the spine surgeon and must be addressed through multidisciplinary, multimodal, and individualized management. The presence of tumor cells in bone metastases results in homeostatic disruption between bone formation and remodeling and leads to osteolytic, osteoblastic, or mixed bone lesions. Spinal metastases are a significant cause for morbidity characterized by severe pain, impaired mobility, pathological fractures, spinal instability, and neurological involvement. Radiographs, magnetic resonance imaging, computed tomography, and positron emission tomography are widely used for the detection and staging of the disease. Histopathological examination is crucial to establish an oncological diagnosis. Our review focuses on epidemiology, pathogenesis, clinical presentation, and diagnosis of spinal metastasis.

111. Can body composition measures on computed tomography predict mortality in patients with spinal metastases undergoing surgery?

<h3>BACKGROUND CONTEXT</h3> Although survival of patients with spinal metastases has improved in recent decades due to advances in multimodal therapy, there are currently no reliable predictors of mortality. Computed tomography (CT) body composition measurements have been recently proposed as biomarkers for survival in patients with and without cancer. Patients with cancer routinely undergo CT for staging or surveillance of therapy and body composition assessed using opportunistic CTs might be used to determine survival in patients with spinal metastases. <h3>PURPOSE</h3> The purpose of our study was to determine the value of body composition measures obtained on opportunistic abdomen CTs to predict 90-day and 1-year mortality in patients with spinal metastases undergoing surgery. We hypothesized that low muscle and abdominal fat mass were predictors of mortality. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort. <h3>PATIENT SAMPLE</h3> Between 2001 and 2016, 196 patients who underwent surgery for spinal metastases at a single tertiary center underwent CT of the abdomen within three months prior to surgery. <h3>OUTCOME MEASURES</h3> Ninety-day and 1-year mortality. <h3>Methods</h3> Quantification of cross-sectional areas (CSA) and CT attenuation in Hounsfield units (HU) of abdominal subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), and paraspinous skeletal muscle were performed on CT images at the level of L4 using an in-house automated algorithm under the supervision of a fellowship-trained musculoskeletal radiologist. Sarcopenia was determined by total muscle area (cm²) divided by height squared (m²) with cutoff values of <52.4 cm²/m² for men and <38.5 cm²/m² for women. Bivariate and multivariate Cox proportional-hazard analyses were used to determine the associations between body compositions and 90-day and 1-year mortality. <h3>Results</h3> The median age was 62 years (interquartile range = 53-70). Mortality rates at 90 days and 1 year were 24% and 54%, respectively. Sarcopenia and decreased muscle attenuation were associated with increased mortality for both timepoints (p=0.04 and p=0.04, respectively) after controlling for sex, age, body mass index, Charlson Comorbidity score, primary tumor type, visceral metastases, and duration between diagnosis of spinal metastases and surgery. Decreased SAT area was associated with increased 90-day mortality after controlling for the same covariates (p<0.01). <h3>Conclusions</h3> Decreased muscle attenuation and sarcopenia are independently associated with an increased risk of 90-day and 1-year mortality for patients surgically treated for spinal metastases, and low SAT CSA is independently associated with increased risk of 90-day mortality. Therefore, body composition measurements could serve as novel biomarkers for prediction of mortality in patients with spinal metastases. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Clinical characteristics and surgical treatment of spinal metastases from pancreatic cancer: a single-center retrospective study.

To improve the understanding of the characteristics of rare pancreatic cancer spinal metastatic disease and share our experience in coping with this disease. Although spinal metastasis of pancreatic cancer is extremely rare clinically, and the prognosis of the primary tumor is very poor, pancreatic cancer spinal metastasis has received insufficient attention in clinical practice and is only described in a limited number of case reports or series. The purpose of the present study is to discuss the clinical features, prognostic characteristics, and treatment of individuals with pancreatic cancer spinal metastases. Four patients with clinical symptoms caused by metastatic spinal pancreatic cancer (MSPC) were selected from patients treated in our department between January 2010 and January 2020. Patients' clinical and surgical records, imaging data, and pathology reports were reviewed by our team. A retrospective analysis of patient clinical data was conducted. Of the four patients, one was male and three were female. The average age was 68.0 (range: 61-79) years old. The average time between the pancreatic cancer diagnosis and the diagnosis of spinal metastases was 10.5 (range: 0-24) months. Spinal metastatic disease was primarily found in the thoracic spine (n=3; 75.0%), and the lumbar spine (n=2; 50.0%). During follow-up, local tumor progression was found in all four patients (100%), all of whom died of pancreatic cancer during follow-up visits. The median time between spinal surgery and death was 16.3 (range: 12-19) months. Taken together, pancreatic cancer patient that have spinal metastases exhibit a poor prognosis, with a survival time shorter than for any other malignant tumor. Percutaneous vertebroplasty may become an effective treatment option for pancreatic cancer spinal metastasis, which can significantly improve the patient's symptoms.

Clinical characteristics and surgical treatment of esophageal cancer spinal metastasis – A single center 10-year retrospective study

ObjectiveOur research aims to discuss the clinical characteristics, treatment methods, and prognostic characteristics of patients with esophageal cancer spinal metastasis. It is one of the largest clinical studies on the disease to date. The purpose is to improve clinicians’ understanding of the clinical features and prognosis of esophageal spine metastases and share our experience in dealing with this entity. MethodsSix patients with spinal metastasis due to esophageal cancer who had received surgical treatment at the bone tumor center of Peking Union Medical College Hospital from January 2010 to January 2020 were selected. The clinical data, surgical records, imaging examinations, pathological reports, and immunohistochemical results of all patients were reviewed by the team. In the study, we applied two surgical treatments, namely open surgery and percutaneous vertebroplasty. Radiotherapy, chemotherapy, and targeted therapy were used as adjuvant treatments. Retrospective analysis of the patient’s basic clinical data were analyzed. ResultsAll six patients with metastatic spinal esophageal cancer (MSEC) were male with an average age of 58.0 ± 5.3 years. The average duration between the esophageal cancer resection and diagnosis of spinal metastases was 24.8 (2–72) months. Of the six patients, four had spinal metastases located in the thoracic spine and two had metastases located in the lumbar spine. We referred to the revised Tokuhashi score and Tomita score to recommend individualized surgical treatment plans for patients, and fully respected the patients’ wishes. All six patients underwent surgical treatment, a total of six operations, including four percutaneous vertebroplasty and two open surgery. After the operations, the symptoms of the patients improved significantly. During the follow-up, all six patients died of the disease with the average time from spinal surgery to death being 8.8 ± 3.7 months. ConclusionsIn general, patients with esophageal cancer spine metastases have a poor prognosis, and the average survival time of these patients often does not exceed 12 months. The combination of surgical treatment and postoperative adjuvant therapy can control symptoms effectively and improve the patient’s quality of life.

Comparison of diagnostic efficacy of MRI and PET/CT in lung cancer of mouse with spinal metastasis

This study aimed to compare the diagnostic efficacy of MRI and PET/CT in lung cancer of mouse with spinal metastasis. 40 healthy Balb/c nude mice were selected. 0.1 ml of human lung cancer cell A549 bacterial suspension was injected by the left ventricle injection method to establish a lung cancer spinal metastasis model, and the abnormal signs of the nude mice were closely observed. When the body weight was reduced by 20%, micro PET/CT imaging and small coil MRI imaging were applied after intraperitoneal injection of thiopental anesthesia in nude mice. After the imaging was completed, the nude mouse was dissected and the spinal tumor was removed. The nature of spinal metastases was diagnosed by the pathology department. 5 nude mice died of abdominal infection, 2 nude mice had no spinal tumors, and the remaining 33 nude mice were successfully modeled. 33 nude mice were confirmed by pathology to have 64 metastatic vertebral lesions, among them, there were 7 cervical vertebrae, 24 thoracic vertebrae, 16 lumbar vertebrae, 6 sacral vertebrae and 11 caudal vertebrae. The sensitivity of MRI in the diagnosis of spinal metastases was 78.13%, and specificity was 56.25%. The sensitivity of PET/CT for the diagnosis of spinal metastases was 92.19%, and specificity was 78.95%. The specificity and positive predictive value of PET/CT for the diagnosis of spinal metastases were not significantly different from those of MRI (P&gt; 0.05). The sensitivity, accuracy and negative predictive values were significantly higher than those of MRI (P&lt; 0.05). PET/CT is superior to MRI in the diagnosis of spinal metastases, and its sensitivity, accuracy and negative predictive values were significantly higher than those of MRI (P&lt; 0.05). It is worthy to be further promoted in clinical practice.

THE SINS SCALE IN THE EVALUATION OF STABILITY IN PATIENTS WITH SPINAL METASTASIS

ABSTRACT Objective To evaluate the distribution of patients seen in the emergency care unit of the Instituto do Câncer do Estado de São Paulo in the categories “stable”, “indeterminate” and “unstable” as classified by the SINS scale. Methods The medical charts of patients treated between May and September 2013 were reviewed. Patients with a diagnosis of spinal metastasis were analyzed and data on age, sex, primary tumor location, neurological status, and the presence and intensity of pain at rest and in movement were obtained. The SINS criteria were used to evaluate the radiological involvement of the spine. Results We included 81 patients with a mean age of 59.57 years; 32 (39.51%) men and 49 (60.49%) women. Breast (19.75%), prostate (18.52%) and lung (17.28%) were the most common primary tumor sites. Only 18 patients (22.22%) had a single lesion and 51 (62.96%) had 3 or more metastatic lesions. Of the total, 56 (69.14%) were of undetermined stability, 19 were stable (23.46%) and 6 were unstable (7.41%). Twenty-two (27.2%) presented neurological deficit in the physical examination. None of the patients with severe deficit, Frankel A or B, were stable according to the SINS classification. All unstable lesions presented with kyphotic and/or scoliotic deviation (p &lt;0.001). Most patients with undetermined lesions (78.6%) and all patients with unstable lesions had mechanical pain (p = 0.001). Conclusion In this case series, there was a high rate of patients classified by the SINS scale as of undetermined instability (69.14%). There was a high number of patients with multiple metastases (62.96%), which was not considered a modifier of the SINS instability criteria and which needs to be the focus of future studies. Level of evidence IV; Case Series.

Clinical features and surgical treatments of rare gastrointestinal stromal tumor spinal metastases

Objective To increase our knowledge of the characteristics of rare gastrointestinal stromal tumors (GISTs) spinal metastatic diseases and share our experience of dealing with these diseases. Methods A total of 6 patients with spinal cord compression caused by GISTs spinal metastases operated in our department were identified from Oct, 2010 to Oct, 2018. The clinical and operative notes, radiographic images, and pathological reports with histochemistry of all these patients were reviewed. Results Among these six, four were male. The average age was 57.2 ± 9.0 years-old. The average duration between GISTs resections and diagnosis of spinal metastases was 80.8 ± 91.9 months. Four patients died from their disease during follow-up. The average duration between operation and death was 8.5 ± 4.4 months. Conclusions Generally, patients with GISTs spinal metastatic diseases had a poor prognosis. The average survival of these patients did not exceed 12 months. Palliative treatments are recommended mainly to control symptoms.

A novel MRI-based score assessing trabecular bone quality to predict vertebral compression fractures in patients with spinal metastasis.

Vertebral compression fractures (VCFs) in patients with spinal metastasis can lead to destabilization and often carry a high risk profile. It is therefore important to have tools that enable providers to predict the occurrence of new VCFs. The most widely used tool for bone quality assessment, dual-energy x-ray absorptiometry (DXA), is not often available at a patient's initial presentation and has limited sensitivity. While the Spinal Instability Neoplastic Score (SINS) has been associated with VCFs, it does not take patients' baseline bone quality into consideration. To address this, the authors sought to develop an MRI-based scoring system to estimate trabecular vertebral bone quality (VBQ) and to assess this system's ability to predict the occurrence of new VCFs in patients with spinal metastasis. Cases of adult patients with a diagnosis of spinal metastasis, who had undergone stereotactic body radiation therapy (SBRT) to the spine or neurosurgical intervention at a single institution between 2012 and 2019, were retrospectively reviewed. The novel VBQ score was calculated for each patient by dividing the median signal intensity of the L1-4 vertebral bodies by the signal intensity of cerebrospinal fluid (CSF). Multivariable logistic regression analysis was used to identify associations of demographic, clinical, and radiological data with new VCFs. Among the 105 patients included in this study, 56 patients received a diagnosis of a new VCF and 49 did not. On univariable analysis, the factors associated with new VCFs were smoking status, steroid use longer than 3 months, the SINS, and the novel scoring system-the VBQ score. On multivariable analysis, only the SINS and VBQ score were significant predictors of new VCFs and, when combined, had a predictive accuracy of 89%. As a measure of bone quality, the novel VBQ score significantly predicted the occurrence of new VCFs in patients with spinal metastases independent of the SINS. This suggests that baseline bone quality is a crucial factor that requires assessment when evaluating these patients' conditions and that the VBQ score is a novel and simple MRI-based measure to accomplish this.

Timing of Adjuvant Radiation Therapy and Risk of Wound-Related Complications Among Patients With Spinal Metastatic Disease.

Study Design:This was an epidemiological study using national administrative data from the MarketScan database.Objective:To investigate the impact of early versus delayed adjuvant radiotherapy (RT) on wound healing following surgical resection for spinal metastatic disease.Methods:We queried the MarketScan database (2007-2016), identifying patients with a diagnosis of spinal metastasis who also underwent RT within 8 weeks of surgery. Patients were categorized into “Early RT” if they received RT within 4 weeks of surgery and as “Late RT” if they received RT between 4 and 8 weeks after surgery. Descriptive statistics and hypothesis testing were used to compare baseline characteristics and wound complication outcomes.Results:A total of 540 patients met the inclusion criteria: 307 (56.9%) received RT within 4 weeks (Early RT) and 233 (43.1%) received RT within 4 to 8 weeks (Late RT) of surgery. Mean days to RT for the Early RT cohort was 18.5 (SD, 6.9) and 39.7 (SD, 7.6) for the Late RT cohort. In a 90-day surveillance period, n = 9 (2.9%) of Early RT and n = 8 (3.4%) of Late RT patients developed wound complications (P = .574).Conclusions:When comparing patients who received RT early versus delayed following surgery, there were no significant differences in the rates of wound complications. Further prospective studies should aim to identify optimal patient criteria for early postoperative RT for spinal metastases.

Clinical and plain x-ray findings of spinal metastases: a retrospective study of pathologically-confirmed cases

Background: Malignancy of breast, prostate, and lung contribute to metastatic bone disease, and the metastases are mostly located in the spine. Spinal metastases may involve the spinal cord, leptomeninges, epidural space and also the bone itself. Therefore, proper imaging is needed in early detection and diagnosis of spinal metastasis. This study aimed to perform the clinical and plain x-ray findings in patients with spinal metastasis.  Method: A retrospective study was conducted on 28 spine pathological fracture patients with neurologic deficits who underwent surgical intervention in Sanglah General Hospital during a year. We evaluated the present symptoms, neurological status (Frankel score), pathological reports by plain x-ray findings, metastases cell type by histological assessment, and extension of mass expansion on MRI. A total of 20 cases that met the inclusion criteria were evaluated.Result: Most patients suffer from pathologic fracture on thoracic spine level, followed by lumbosacral level and none on cervical spine level. The compressive fracture was a major finding on plain x-ray. The extradural lesions account for most of the MRI findings, followed by intradural/extramedullary and intramedullary lesion. Primary tumours that lead to bone metastases in this serial-cases are prostate, breast, cervix, kidney and lung cancer, respectively.Conclusion: Thoracic spine is the most common spinal metastases manifestation. Conventional plain x-ray is the most initial modality to evaluate systemic neoplasia patients with spinal pain, although it is not a sensitive indicator to identify the presence and extent of metastatic involvement.

Feasibility and preliminary clinical results of linac-based Stereotactic Body Radiotherapy for spinal metastases using a dedicated contouring and planning system

BackgroundStereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT) are well established local treatment approaches in several cancer settings. Although SBRT is still under investigation for spinal metastases, promising results in terms of a high effectiveness and optimal tolerability have been recently published on this topic. For spinal SBRT, one of the most relevant issues is represented by the inter-observer variability in target definition. Recently, several technological innovations, including specific tools such as multimodality-imaging (computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET-CT), automated volumes contouring and planning, could allow clinicians to minimize the uncertainties related to spinal SBRT workflow. Aim of this study is to report the feasibility of the clinical application of a dedicated software (Element®, Brainlab™ Germany) for spinal metastases SBRT.Material and methodThe patient selection criteria for SBRT in spinal metastases were the following: age > 18 years, diagnosis of spinal metastases (n ≤ 3), life expectancy > 3 months, controlled primary tumor or synchronous diagnosis and Spinal Instability Neoplastic Score (SINS) ≤ 12 points. All radiation target volumes were defined and planned with the support of the dedicated software Elements® (Brainlab™ Germany). Different dose prescription have been used: 12 Gy in single fraction, 12 Gy, 18 Gy, 21 Gy and 24 Gy in 3 fractions. Toxicity was assessed according to the Common Terminology Criteria for Adverse Events (CTCAE) v4.0. SPSS version 20 was used for statistical analysis.ResultsFrom April 2018 to April 2019, 54 spinal metastases in 32 recruited patients were treated with Linac-based SBRT. With a median follow-up of 6 months (range 3–12), local control rates at 6 months and 9 months were 86 and 86%, respectively. No adverse events ≥3 grade were observed.ConclusionsThis preliminary experience shows that with respect to acute toxicity and early clinical response, linac-based using Elements® Spine SRS is a feasible and effective approach.

Diagnosis of spinal metastasis: are MR images without contrast medium application sufficient?

ObjectiveTo determine the usefulness of adding contrast-enhanced (CE) magnetic resonance imaging (MRI) to conventional MRI for evaluation of spinal metastases. Materials and methodsOne-hundred-and-two whole spine MR examinations, obtained for metastasis work-up within a 2-month period, from 65 men and 37 women (mean age, 64 years) with extra-spinal tumor, who also underwent CE-MRI, were retrospectively evaluated by three radiologists. The number of spine segments with bone marrow involvement was interpreted using a 3-point confidence scale (probable metastasis, equivocal, probably benign) during session 1 (conventional imaging) and session 2 (addition of CE-MRI to conventional imaging). The patients were assigned to 14 categories based on the changes in confidence rating between sessions 1 and 2; these were aggregated to four groups indicating the degree of usefulness of CE-MRI: definitely useful, equivocal, not useful, and presumed non-metastatic groups. Clinical information, metastatic bone type, the number of probably metastatic segments, and anatomical level and position were compared among the former three groups. ResultsThe readers assigned 39–53% of cases to the definitely useful group. The number of probably metastatic segments differed significantly among the three groups for all readers (p ≤ 0.046). Age, sex, primary cancer, metastatic bone type, and anatomical level and position were similar. ConclusionAdding CE-MRI to conventional MRI was useful for objectively detecting and characterizing spinal segments with metastases in 39–53% of cases. However, there were no clinical or radiological factors that could predict the usefulness of CE-MRI in evaluating spinal metastases, except for the number of metastatic segments.

Prognostic evaluation of patients with metastatic spinal tumors using modified Tokuhashi's score: A retrospective study

Introduction: Tokuhashi's scoring has been used as a presurgical tool for prediction of survival in patients with spinal metastases (SM). It evaluates prognostic factors such as performance status, number of extraspinal bone metastasis, metastasis to visceral organs, site of primary, and neurological status that determine the survival in these patients. To the best of our knowledge, only limited studies are available to use this scoring system to determine survival outcomes in patients with SMs undergoing palliative radiotherapy. Aim: The purpose of our study was to determine the patient characteristics and usefulness of modified Tokuhashi's score in determining survival in patients with SM. Methods: This is a retrospective study of patients who underwent radiotherapy for SM from January 2013 to December 2017. Results: Seventy patients with SM from solid tumors were included in the study. The male to female ratio was 1.3:1. The median ageat diagnosis of SM was 50 years. The median survival was 7 months. The modified Tokuhashi's score ranged from 0 to 13, and the mean score was 6. In our study, 46 belonged to the poor prognostic group, 20 belonged to the moderate prognostic group, and 4 patients belongedto good prognostic group with a median survival of 4.8, 13.5, and 28 months, respectively. There was a statistical significance in the difference in survival in three prognostic groups. Conclusion: Our study confirms the usefulness of modified Tokuhashi's score in determining the survival outcomes in patients with metastatic spinal tumors.

Prognosis of Single Spinal Metastatic Tumors: Predictive Value of the Spinal Instability Neoplastic Score System for Spinal Adverse Events.

Study DesignThis was a retrospective cohort study.PurposeWe evaluated the predictive value of the Spinal Instability Neoplastic Score (SINS) system for spinal adverse events (SAEs) in patients with single spinal metastatic tumor.Overview of LiteratureThe SINS system was developed to assess spinal instability in patients with single metastatic spinal tumor. However, the system’s potential predictive value for SAEs has been partially studied.MethodsThis system was applied to a retrospective cohort of 78 patients with single spinal metastatic tumors. The patients underwent surgical treatment and were postoperatively followed up for at least 2 years or until death. The attribution of each score and total SINS to SAE (vertebral compression fracture [VCF] and spinal cord compression [SCC]) occurrence was assessed using the Cox proportional hazards model.ResultsSAEs occurred on average 7 months after diagnosis of spinal metastasis. The mean survival rate post diagnosis was 43 months. Multivariate analysis using the Cox proportional hazards model revealed that the pain (p=0.029) and spinal alignment (p=0.001) scores were significantly related to VCF occurrence, whereas the pain (p=0.008) and posterolateral involvement (p=0.009) scores were related to SCC occurrence.ConclusionsAmong the components of the SINS system, while pain and spinal alignment showed a significant association with VCF occurrence, pain and posterolateral involvement showed association with SCC occurrence.

Functional and survival outcomes in patients undergoing surgical treatment for metastatic disease of the spine.

Retrospective review of a prospective database. Spine metastasis has been shown to occur in 40% of cancer patients with an annual incidence of over 18,000 cases in North America alone. In this study, we sought to explore the functional and survival outcomes of patients undergoing surgical treatment for metastatic disease of the spine. A retrospective cohort study of a prospective database at a major cancer center was conducted. A total of 55 patients who met the inclusion criteria from January 2010 to December 2015 were included. Functional status was assessed through patient's ambulatory status. Patient and tumor characteristics were analyzed and regression analyses were performed. Renal cell carcinoma (RCC) was the most common subtype encountered (27.3%). Excluding patients who had spinal metastasis at time of diagnosis, the median time to spinal metastasis from cancer diagnosis was 2.5 years. Median overall survival (OS) time was 1.8 years post diagnosis and 1.6 years post-surgical intervention. Age and tumor subtype were independent predictors of death (P<0.05). Post-surgical intervention, only 3.6% of patients were unable to ambulate-an improvement from 12.7% seen in the immediate preoperative period, P=0.0253. However, at the time of final follow-up, this number had risen to nearly 37%, P<0.0001. Spinal metastasis portends a debilitating prognosis. Ambulatory status is improved or maintained in the post-surgical period. However, long-term outlook remains dismal with median survival at only 1.8 years following diagnosis of spinal metastasis and ambulatory status declining precipitously at the time of final follow-up.

Anatomic and functional imaging in the diagnosis of spine metastases and response assessment after spine radiosurgery.

Spine stereotactic radiosurgery (SSRS) has recently emerged as an increasingly effective treatment for spinal metastases. Studies performed over the past decade have examined the role of imaging in the diagnosis of metastases, as well as treatment response following SSRS. In this paper, the authors describe and review the utility of several imaging modalities in the diagnosis of spinal metastases and monitoring of their response to SSRS. Specifically, we review the role of CT, MRI, and positron emission tomography (PET) in their ability to differentiate between osteoblastic and osteolytic lesions, delineation of initial bony pathology, detection of treatment-related changes in bone density and vertebral compression fracture after SSRS, and tumor response to therapy. Validated consensus guidelines defining the imaging approach to SSRS are needed to standardize the diagnosis and treatment response assessment after SSRS. Future directions of spinal imaging, including advances in targeted tumor-specific molecular imaging markers demonstrate early promise for advancing the role of imaging in SSRS.

Prognostic Factors Influencing the Outcome of 64 Consecutive Patients Undergoing Surgery for Metastatic Melanoma of the Spine.

Melanoma metastases to the spine remain a challenge for neurosurgeons. To identify factors associated with survival in a series of patients who underwent spinal surgery for metastatic melanoma. We retrospectively reviewed all patients (n = 64) who received surgical intervention for melanoma metastases to the spine at the University of Texas MD Anderson Cancer Center between July 1993 and March 2012. No patients were excluded from the study, and vital status data were available for all patients. Median overall survival was 5.7 months (95% confidence interval, 2.7-28.7). On univariate survival analysis, diagnosis of spinal metastasis after prior diagnosis of systemic metastasis, higher total spinal disease burden (including but not exclusive to the operative site), presence of progressive systemic disease at the moment of spine surgery, and postoperative complications were associated with poorer overall survival, whereas the presence of only bone metastasis at the moment of surgery was associated with improved overall survival. On multivariate survival analysis, both progressive systemic disease at the moment of spine surgery and total spinal disease burden of ≥3 vertebral levels were significantly associated with worse overall survival (hazard ratio, 6.00; 95% confidence interval, 3.19-11.28; P < .001; and hazard ratio, 2.87; 95% confidence interval, 1.62-5.07; P < .001, respectively). On multivariate analysis, involvement of ≥3 vertebral bodies and progressive systemic disease were associated with worse overall survival. Consideration of these factors should influence surgical decision making in this patient population.

Current trends in mini-invasive management of spine metastases.

The spine is a frequent localization of primary tumours or metastasis involving posterior arch, pedicles and vertebra body, and often causing unsustainable pain. The management of spinal metastasis remains complex, including medical therapy (corticosteroids, chemotherapy), radiotherapy and surgical treatment, or the recent percutaneous mini-invasive approach. The target of all these treatments is to improve the quality of life of patients affected by this type of lesion. Diagnosis of spinal metastasis and then its treatment should be based on the combination of different elements: clinical evaluation, CT, MRI and nuclear medicine patterns, considering the age of the patient, known primary tumour, location of the lesions, single/multiple lesions, pattern of morphology (border, matrix, expansile character, soft tissue extension), density or signal intensity, oncologic instability and expectancy of life. The percutaneous mini-invasive approach for patients affected by secondary lesions involving the spine has as treatment goal of: (1) pain relief improving the quality of life; (2) stability treatment re-establishing the spinal biomechanics, alterated by bone destruction or deformity, preventing pathological fracture; and (3) an anti-neoplastic effect. The aim of this paper is to provide a comprehensive diagnostic and percutaneous approach to the bone metastatic spine lesions, identifying which metamer should be treated to improve patient quality of life, showing the importance of a multi-disciplinary approach to this problem.

Results of kyphoplasty in the minimally invasive treatment of vertebral metastasis

OBJECTIVE: To evaluate the clinical and radiological outcome of minimally invasive surgical treatment of vertebral metastases using the technique of kyphoplasty. METHODS: This was a prospective observational study of patients with the diagnosis of spinal metastasis who underwent minimally invasive surgical treatment by filling the vertebral body with balloon kyphoplasty technique. Clinical evaluation included patient age at surgery, diagnosis of the tumor, biopsy results, data of the surgical procedure performed, visual pain scale (VAS) and complications related to surgery. Radiological evaluation involved the study of radiographic procedures in the anteroposterior and lateral incidences, with the analysis of vertebral body kyphosis and the occurrence of extravasation of cement. RESULTS: 22 patients with spinal metastases who were treated by balloon kyphoplasty, 8 (36%) males and 14 (64%) females were studied. The average age was 56.05 years and the mean follow-up was 8.5 months. The mean preoperative VAS was 8.73, 1.73 in the initial postoperative period, and 1.92 in the late postoperative period. CONCLUSION: Kyphoplasty proved to be a safe and effective technique for symptomatic treatment of vertebral metastases.

Predictors of survival in patients with prostate cancer and spinal metastasis

ObjectProstate cancer is the second most common malignancy to cause death in men, with metastases to the spine being the most common site of metastatic burden. A retrospective observational study was performed to determine survival of patients in whom spinal metastasis from prostate cancer had been diagnosed.MethodsThe patient population was obtained from the Prostate Clinical Research Information System (CRIS) at the Dana-Farber Cancer Institute. Patients were observed over a period of 19 years, between June 1990 and April 2009. Clinical covariates were studied in their relationship to overall survival, the primary outcome, by using the Kaplan-Meier method and Cox regression.ResultsOf a total of 9010 patients in the Prostate CRIS database, 333 were identified as having developed spinal metastases. The median overall survival after diagnosis of spinal metastasis was 24 months (95% CI 21–28 months). The estimated 1-year overall survival was 73% (95% CI 67%–77%). In 85% of patients, at least 1 additional site of metastasis was documented. Among 28 patients who had no additional sites of metastases, the median survival was 55.9 months, whereas an increasing burden of disease was associated with shorter survival (p = 0.0001). The association was observed regardless of whether the metastatic burden was characterized as the presence of additional (nonspinal) bone metastasis, the presence of additional nonbone metastasis, or as the number of concomitant metastatic sites (all p = 0.0001). In multivariate analysis, a higher prostate-specific antigen level at the diagnosis of spinal metastasis, a longer duration between the diagnosis of prostate cancer and spinal metastasis, and the presence of additional metastasis at the time of diagnosis of spinal metastasis (all p = 0.0001) were independently associated with a shorter overall survival.ConclusionsThe results of this study are important for oncologists, neurosurgeons, and primary care physicians who have patients with prostate cancer that metastasizes to the spine, because these results can be used to form a prognosis and guide the physician in making appropriate decisions regarding the patient's treatment. Future work should include building a predictive model that accurately determines survival in patients with metastatic disease, because this would guide the physician in devising the most appropriate treatment plan for each patient.