Incidence Of Spinal Metastases Research Articles

Development of a core outcome set of clinical research on the integration of traditional Chinese and Western medicine for spinal metastases: a study protocol

BackgroundIn recent years, the incidence of spinal metastasis (SM) has been increasing steadily. In response to this serious public health problem, researchers have made progress by using the integration of...

Surgical strategy for metastatic spinal tumor patients with surgically challenging situation.

The incidence of spinal metastasis is increasing as cancer patients live longer owing to the improvement of cancer treatments. However, traditional surgery (TS) which fixates at least 2 levels above and 2 levels below the affected vertebrae is sometimes difficult to perform as it is burdensome to the patients. In this article, we introduce our experience and strategy in treating spinal metastasis, focusing particularly on challenging cases.We retrospectively reviewed the data of 110 patients who underwent spinal surgery for metastatic spinal tumors from April 2018 to March 2020. Among them, 5 patients who received anterior approach surgery were excluded. The remaining 105 patients were enrolled. In addition to TS, we also performed cervical pedicle screw, cervicothoracic junction fixation, thoracolumbar short fixation, and decompression surgery, depending on the characteristics of the tumor. The overall survival was analyzed, and the local tumor control rate was evaluated using magnetic resonance imaging. Perioperative clinical characteristics including Spine Oncology Study Group Outcomes Questionnaire, visual analog scale, Eastern Cooperative Oncology Group performance score, and Karnofsky Performance Score were also investigated.The overall survival rate was 57.9% at 1 year, and the local tumor control rate was 81.1% after surgery. There was a statistically significant difference according to the type of the tumor in the survival analysis: the overall survival rates were 72.7% for favorable tumors and 48.6% for unfavorable tumors at 12 months after surgery (P = .04). Spine Oncology Study Group Outcomes Questionnaire, visual analog scale, Eastern Cooperative Oncology Group performance score, and Karnofsky Performance Score was improved after surgery. All surgical methods, including TS, cervical pedicle screw, cervicothoracic junction fixation, thoracolumbar short fixation, and decompression surgery, showed good clinical and radiological outcomes.Optimized surgical methods show similarly good clinical outcomes in managing spinal metastasis as TS.

Risk factors for wound-related complications after surgical stabilization of spinal metastases with a special focus on the effect of postoperative radiation therapy

BackgroundAdvancements in the field of oncological therapies during the last decades have led to a significantly prolonged survival of cancer patients. This has led to an increase in the incidence of spinal metastases. The purpose of this study was to assess risk factors for wound-related complications after surgical stabilization of spinal metastases with a special focus on the effect of postoperative RT and its timing.MethodsPatients who had been treated for metastatic spine disease by surgical stabilization followed by radiotherapy between 01/2012 and 03/2019 were included and a retrospective chart review was performed.ResultsOf 604 patients who underwent stabilizing surgery for spinal metastases, 237 patients (mean age 66 years, SD 11) with a mean follow-up of 11 months (SD 7) were eligible for further analysis. Forty-one patients (17.3%) had wound-related complications, 32 of them before and 9 after beginning of the RT. Revision surgery was necessary in 26 patients (11.0%). Body weight (p = 0.021), obesity (p = 0.018), ASA > 2 (p = 0.001), and start of radiation therapy within 21 days after surgery (p = 0.047) were associated with an increased risk for wound complications. Patients with chemotherapy within 3 weeks of surgery (12%) were more likely to have a wound-related surgical revision (p = 0.031).ConclusionBody weight, obesity and ASA > 2 were associated with an increased risk for wound complications. Patients with chemotherapy within 3 weeks of the surgery were more likely to have a wound-related revision surgery. Patients who had begun radiation therapy within 21 days after surgery were more likely to have a wound complication compared to patients who waited longer.

Spine Metastasis in Elderly: Encouraging Results for Better Survival.

The incidence of spinal metastasis (SpM) is increasing, and life expectancy for patients with malignancy is also rising. The "elderly" represent a population with steady growth in SpM proportion. Bracing is associated with lower survival. We believe that surgery should be considered, regardless of the patient's age.

Presentation of spinal cord and column tumors.

Metastatic spine disease occurs in more than 10% of all cancer patients. Advances in systemic treatment for cancer has led to improved overall survival for many types of cancer, which has increased the overall incidence of spinal metastases. The most common presenting complaint of patients with spinal metastases is pain. Pain originating from spinal metastases can be oncological, mechanical, and/or neurological in nature. Early recognition of these symptoms is helpful to guide treatment and accurately gauge patient prognosis. Unfortunately, the prevalence of degenerative back pain in the general population can complicate early clinical recognition of patients with metastatic spine disease. Therefore, back pain in any patient with a history of malignancy should prompt clinicians to perform an expedited workup for metastatic disease of the spine. Diagnostic imaging and laboratory studies are part of the initial work up. Obtaining pathology via biopsy to establish tumor histology is essential to determine the appropriate treatment.

Multimodal imaging of composite carbon fiber-based implants for orthopedic spinal fixation.

As cancer treatments continue to improve, the incidence of spinal metastases and the need for surgical management of these with fixation procedures are growing rapidly. Traditionally metallic implants, composed of titanium alloy, have been used in surgical fixation of unstable or symptomatic vertebral metastases or traumatic injuries. Metallic implants, however, cause significant artifact on post-operative imaging, degrading image quality and limiting interpretation, and can also impair the planning and delivery of radiotherapy. Composite carbon fiber-based materials, such as carbon fiber-reinforced polyetheretherketone (PEEK), have been developed to overcome these issues and are now available for spinal fixation procedures. We aimed to review the multimodal imaging features of these new implants. Current literature and a case example from our institution were used to describe the multimodal imaging characteristics and considerations of new carbon fiber-based spinal fixation implants. New carbon fiber-based spinal implants allow far greater visualization of surrounding structures on post-operative cross-sectional imaging, significantly improving diagnostic accuracy and precision of radiotherapy planning, and do not significantly absorb or scatter X-ray photons during radiotherapy delivery. There are, however, important surgical and radiologic considerations associated with the use of carbon fiber-based implants which radiologists must be aware of, such as implications for surgical planning and intra-operative fluoroscopic and post-operative plain radiographic imaging. The use of carbon fiber-based implants, rather than traditional metallic implants, for spinal fixation offers significant advantages for post-operative diagnostic imaging and radiotherapy planning and delivery.

Extracranial Metastasis of IDH-1 Wild Type Glioblastomas.

To identify the effects of different immunohistochemical features of glioblastomas with spinal metastases based on the metastatic spread and survival rate. A total of 214 patients who were diagnosed with and operated for brain tumor in our clinic between 2007 and 2018, and pathologically diagnosed with glioblastoma were retrospectively evaluated. Among them, 141 medical records were reviewed, and 23 of them underwent spinal magnetic resonance imaging postoperatively due to various complaints. All patients with glioblastoma with spinal metastases had negative isocitrate dehydrogenase 1 (IDH-1) in the immunohistochemical examination. The incidence of spinal metastasis is 1.91%. The median Ki-67 index is 30 (range, 4-90; median Ki-67 index: 30+/-18.5). IDH mutation is wild in 55%, mutant in 33%, and not otherwise specified in 12%. Four patients with spinal metastasis has wild-type IDH with mean Ki-67 index of 60, and one of them was a woman (25%) and the remaining three were men (%75), with mean age of 32 years. Gliomas with high immunohistochemical proliferation indexes and wild-type IDH with poor prognostic features based on the new classification tended to metastasize to the spine in the early disease stage; therefore, early spinal scanning and radiation therapy might extend the life expectancy. High Ki-67 index and the presence of wild-type isocitrate dehydrogenase may be the predictive factors for spinal screening.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters

BACKGROUND CONTEXT While the incidence of spinal metastases is constantly increasing, the combination of kyphoplasty and intraoperative radiation (Kypho-IORT) is a good possibility not only to gain additional histopathologic data but also to achieve excellent pain and local tumor control. The clinical effectiveness in terms of local tumor control is comparable to SBRT, the pain control far better. The pros of Kypho-IORT are the minimal invasiveness and the one-stop-shop-procedure with effective and instantaneous pain control. PURPOSE The aim of this study is the retrospective density-corrected dose planning in the tumor and the proof of safety for the risk-organ spinal canal on basis of consecutive clinical performed Kypho-IORTs. STUDY DESIGN/SETTING Experimental study, single cohort. PATIENT SAMPLE A total of 10 consecutive cases appointed for Kypho-IORT. OUTCOME MEASURES Sufficient dosing of the metastasis sparing of organs at risk. METHODS We performed Monte-Carlo-based 3D-dose planning in the tumor and in the spinal canal, by using the new planning-software Radiance (GMV Healthcare, Madrid, Spain) in 10 consecutive Kypho-IORTs (Dose 8 Gy in 13 mm distance from the isocenter, 50 kV-xray-source, Intrabeam XRS4, Zeiss meditech AG). Pre- and intraoperative imaging (cone-beam-CT: Siemens Zeego) was used for the dose calculation. Due to metal-artifacts in the intraoperative-cone-beam-CT a preoperative multislice-CT had to be used for calculating the dose, therefore a matching of both CTs had to be performed. RESULTS The distance of the geometrical centre of the metastasis and the coordinates of the applicator tip (isocenter of radiation) could be calculated by vector analysis, the dose distribution was calculated density-corrected. In 7 out of 10 cases, the distance was larger than 5 mm, not correlating to the size of the metastasis itself. In 8 of 10 cases, 70% of the metastasis volume was treated with the prescribed dose of 8 Gy, in 2 cases this treatment-goal was missed. In all 10 cases no dose over 8 Gy reached the spinal canal, the myelon was never exposed to a potential harmful dose. CONCLUSIONS We could show that the Kypho-IORT is not only an effective and safe method, but also an exact quantifiable method, especially in contrast to other methods like thermoablation. The organs at risk are not exposed to a critical dose, the metastasis volume was acceptable covered (8/10 cases >70% of the volume treated with >8 Gy).The next step to further enhance the potential of the procedure in terms of a patient individual dosage will be the intraoperative dose-planning and modification of the delivered dose. A different approach via inverse-planning could be the navigation of the applicator.But also without individual dose-planning Kypho-IORT reached excellent clinical results in terms of local tumor control by using the standard dose of the dose-escalation trial (8 Gy in 13 mm distance of the Isocenter).

Change of paradigm in the surgical treatment of metastatic diseases of the bone. Part II. Treatment of spinal metastases

The incidence of spinal metastases is constantly growing, but due to the advancements in oncologic treatment methods, the survival and the quality of life of the patients are persistently improving. Choosing the optimal treatment method is essential, and several factors should be considered: type of the primary tumor, segmental stability, the symptoms caused by the metastasis and the general condition of the patient. Using modern radiotherapeutic methods combined with minimally invasive surgical techniques (minimally invasive stabilization, separation surgery) in the majority of patients permits adequate local control with low complication rate. In our review, we describe the state-of-the-art, modern spinal metastasis treatment options based on the recently published evidence. Orv Hetil. 2018; 159(8): 297-302.

Interpretation of MR Imaging of Spinal Metastasis: Focus on the Understanding of Its Pathophysiology and the Next Step toward a Further Clinical Approach Using MRI Findings

The spine is the most common site for skeletal metastases, and the incidence of spinal metastasis tends to increase due to the increase in older populations and improvements in medical treatment, such as chemotherapy and radiotherapy (1, 2). However, previous reports have focused on tumor detection and the differential diagnosis with other diseases and it was insufficient to provide physicians with practical information for the treatment of spinal metastasis. Spinal metastasis results in neural compression and spinal column instability that can be cause significant pain, neurologic complications or both (3). These clinical representations of spinal metastasis seem to be correlated with the pathophysiology of the spinal metastasis described in the past (4). Therefore, we propose two learning objectives in our study. The first is to understand the pathophysiology of the spinal metastasis resulting in clinical symptoms and complications. The second is to evaluate the MR examination while focusing on some analysis points providing practical and useful information regarding the next step for a further developed clinical approach. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Received: February 16, 2016 Revised: March 21, 2016 Accepted: March 22, 2016

Operative therapy of spinal metastases from urological tumors

The treatment of bone metastases from urological tumors represents a palliative form of therapy, apart from the resection of solitary metastases from renal cell carcinomas. Due to the high incidence of spinal metastases this can result in clinically significant symptoms and possible complications for patients, such as pain, spinal instability and compression of the spinal canal with corresponding neurological deficits. By the use of targeted diagnostics and induction of radiotherapeutic and/or surgical treatment, for the majority of patients an immediate reduction in pain as well as early mobilization and sometimes even regression of existing neurological deficits and therefore an improved quality of life can be achieved.

Validation of the Spinal Instability Neoplastic Score: A Retrospective Analysis

Introduction With improved survival rates of cancer patients, the incidence of spinal metastases is increasing. Spinal metastases increase the risk for pathological fractures that subsequently increase the risk of spinal instability, spinal cord compression, and neurological compromise. The Spinal Instability Neoplastic Score (SINS) was developed by the Spinal Oncology Study Group (SOSG) to assess neoplastic-related spinal instability and to provide a tool to guide referrals between the appropriate oncology specialists. Considering the multidisciplinary aspect of care of metastatic cancer patients, reliability of the SINS was tested among radiation oncologists and radiologists. Yet, validation of the SINS score has only been done using selected cases by the developers of the SINS. Therefore, the purpose of this study was to retrospectively validate the SINS in the clinical setting. Methods A retrospective database review of patients who underwent palliative surgery or radiotherapy only for the treatment of painful spinal metastases has been conducted. All patients were ambulatory (ASIA E and D) and the two cohorts were matched at the time of follow-up to eliminate neurological compromise and prognosis as indications or exclusion for surgical intervention. Demographics and oncology data were extracted from the hospital charts. The SINS score was calculated based on pretreatment imaging. Results A total of 124 patients were included for analysis. Patients in the surgical cohort were significantly younger and presented more often with a combination of back and radicular pain. The median SINS score in the surgical cohort was 11 (range 7–16) and differed significantly (< 0.001) from the median SINS score of 7 (range 2–16) in the radiation therapy cohort. Sensitivity–specificity analysis showed an optimal cut-off point of a SINS score of 9 for surgical consultation with a sensitivity of 84% and a specificity of 72.6%. The set cut-off value of 7 of the SOSG demonstrated a sensitivity of 96% and a specificity of 41.9% in this analysis. Conclusion In retrospect, a high SINS score corresponded with the indication for surgical intervention for the treatment of neoplastic-related spinal instability.

Kyphoplasty for the Treatment of Malignant Vertebral Compression Fractures Caused by Metastases

Metastatic cancer is the most common malignant disease of the skeletal system, which is the third most common site after the lung and liver. Metastases to the spine are most likely to occur, in 56% of patients with skeletal metastases, the spine is affected. The incidence of spinal metastases has been reported to range from 30% to 70% depending on the primary tumour. Metastatic spinal lesions are commonly associated with bony lesions and skeletal destruction, however, they are usually asymptomatic, and pain is only caused by further vertebral body collapse.

Surgical treatment and outcomes of metastatic breast cancer to the spine

Metastatic vertebral body and spinal epidural lesions cause significant pain and neurological morbidity and negatively impact quality of life and survival. In instances of metastatic epidural spinal cord compression, treatment typically involves surgery and radiotherapy. The incidence of spinal metastases in breast cancer patients is high. In the light of recent improvements in survival among some patients with breast cancer, we reviewed the treatments and outcomes for patients with breast cancer who presented to our institution with metastatic epidural spinal cord compression. We identified all patients undergoing open surgery for the treatment of breast cancer metastases to the spine at our center from 1 January 2001 to 31 December 2009. We retrospectively reviewed records for the details of medical history, treatment, surgery, radiographic imaging, and follow-up. The Death Master File from the United States Social Security Administration was queried to identify the date of death where the medical record was incomplete. Outcomes were assessed by overall survival as well as preoperative and postoperative ambulatory status, bladder function, and the American Spinal Injury Association impairment classification system (ASIA). A total of 15 female patients were identified as having surgical intervention directly related to breast cancer metastasis to the spine. Most lesions (12/15) were located in the anterior vertebral column (vertebral body and/or pedicle). Two patients required re-operation, one for epidural fluid collection and one for infection. Roughly half of the patients (8/15) had well-controlled systemic disease at the time of surgery. Five patients had non-contiguous metastatic lesions elsewhere in the spine. Median survival following surgery was 1025 days; control of systemic disease did not predict duration of postoperative survival. Seven patients had documented improvement in their ability to ambulate in the first 30 days following surgery. Bladder function was preserved in all. No patient deteriorated; and five patients had postoperative improvement of their ASIA impairment scale grade. We concluded that aggressive therapy, including surgery, is warranted for patients with symptomatic metastatic epidural spinal cord compression from breast cancer, including in the setting of advanced and progressive systemic disease.

Percutaneous Vertebral Augmentation in Metastatic Disease: State of the Art

Improvements in diagnosis and treatment have prolonged cancer survival, with a consequent increase in the incidence of spinal metastases and vertebral compression fractures with associated axial pain, progressive radiculomyelopathy, and mechanical instability. Pain relief in malignant vertebral compression fractures is key to achieving a better quality of life in patients under palliative care. The gold standard for pain relief is nonsteroidal anti-inflammatory drugs and opioids. Nonresponsive cases are then treated with radiotherapy, which may require 2-4 weeks to take effect and in most cases does not provide complete pain relief. Percutaneous vertebroplasty and percutaneous kyphoplasty can in particular give relief in patients with vertebral body compression fractures that do not cause neurological deficits but severely compromise quality of life because of intractable pain.

Preoperative Embolization in the Treatment of Spinal Metastasis

Because of advances in the treatment of cancer, the average rate of patient survival is increasing. As patients with cancer live longer, the incidence of spinal metastasis also likely will increase. To help control pain and maintain function, some of these metastases will require surgical intervention. Because >60% of spinal metastases are hypervascular, preoperative embolization may be considered in order to decrease hemorrhage risk and improve outcomes. Embolization for spinal metastasis can be performed through the angiogram catheter. When such embolization is performed carefully, the complication rate is low.

Kyphoplasty with intraspinal brachytherapy for metastatic spine tumors

Among patients with metastatic cancer, an estimated 10% develop malignant lesions to the spine annually in the US, leading to over 120,000 new patients with spinal metastases. Each year, approximately 10–15% of these patients develop symptoms significant enough to require intervention; these symptoms are usually in the form of pain, progressive myelopathy, or pathological vertebral compression fractures.5 Recent advancements in the diagnosis and treatment of systemic cancers have prolonged life and improved the quality of life for cancer patients, but the prolongation of life has been accompanied by an increase in the incidence of spinal metastases. While radiotherapy remained the mainstay of treatment for many years, there is now increasing evidence that surgical intervention in addition to radiation offers superior outcome.9 Vertebroplasty and kyphoplasty have also been well documented to be effective in improving pain from pathological compression fractures in a safe and durable way.4 More recently, the combination of kyphoplasty with radiosurgery has been shown to be effective in treating pathological fracture in patients with spinal metastasis.6 A multimodal treatment approach utilizing systemic chemotherapy, radiation, and surgery has been shown to be beneficial in prolonging survival and offering better local control in patients with intracranial glial tumors.10 Furthermore, multimodal treatment with local chemotherapy, radiation, and surgical excision in a rat spinal metastasis model at our institution validated this approach in the experimental setting.1,2,7,8 In this issue, Cardoso and colleagues present a retrospective case series involving 19 patients with vertebral metastases who underwent percutaneous curettage followed by kyphoplasty with injection of 153Sm-EDTMP mixed with polymethylmethacrylate.3 This procedure allows for tumor debulking, vertebral augmentation, and interstitial radiolabeled particle delivery. These procedures were performed in a minimally invasive manner under local anesthesia with sedation. The authors found that there was no significant myelotoxicity and there was an elevated level of radiolabeled 153Sm at the treated vertebra compared to the systemic level of 153Sm. The patients were found to have improved pain scores—from 8.5 to 2.6 points on a visual analog scale. This is an interesting study of the use of intraspinal brachytherapy with 153Sm-EDTMP. This particle has been used for the treatment of bone metastasis and is effective for pain relief administered by intravenous injection. Although the concept of local delivery of 153Sm is interesting and appealing, it is unclear that there has been any additional benefit of this procedure compared to traditional kyphoplasty. Nevertheless, this is an interesting application of 153Sm locally as a brachytherapy agent in conjunction with curettage and kyphoplasty as a form of multimodal treatment. The authors should be recognized for their novel contribution to the therapeutic options available to patients with metastatic spine tumors. Long-term studies aimed at identifying specific benefits derived from the use of local radiation with 153Sm-EDTMP are needed.