Lumbar Spine Metastasis Research Articles

Lumbar Bone Mineral Density in Prostate Cancer Patients with Bone Metastases

Because of the discrepant findings on regional bone mineral density (BMD) in stage IV patients with bone metastases due to prostate cancer, we decided to evaluate BMD of lumbar spines in 30 prostate cancer patients with lumbar spine metastases. These measurements of BMD in lumbar spines were compared with 30 stage IV prostate cancer patients without lumbar spine metastases. Methods. Before BMD measurements, the bone scan with technetium‐99m labeled diphosphonate was carried out in all of the men to evaluate lumbar spine metastases. Dual energy x‐ray absorptiometry was used to measure BMD in the lumbar spines. Results. There was no difference of age, height, weight, and body mass index between the two group patients. However, significantly higher BMD of the lumbar spines in the 30 patients of prostate cancers with lumbar spine metastases was found ( p value <0.05). Conclusions. Our results show that patients of prostate cancers with lumbar spine metastases demonstrated by Tc‐99m MDP bone scan have increased BMD in the lumbar spines, possibly because of a predominance of osteoblastic over osteolytic metastases demonstrated by Tc‐99m MDP bone scan.

4:41 Metastatic burst fracture risk prediction

Purpose of study: The clinical validity and utility of three biomechanically based predictive models for burst fracture risk in metastatically involved vertebrae were assessed. This study determines the ability of these models to accurately predict vertebral stability and yield clear clinical threshold values for burst fracture risk.Methods used: Digital computed tomography scan images of lytic thoracic and lumbar spinal metastases were categorized as burst fractured, wedge fractured or intact. Stability was analyzed using three predictive models of vertebral load carrying capacity: 1) VBN (maximum radial vertebral bulge under load), 2) VHN (maximum axial vertebral displacement under load), and 3) TS, (percentage volume of tumor). VBN and VHN were previously developed from an experimentally validated finite element model reflecting the biphasic mechanism of burst fracture while incorporating semiautomated estimates of tumor volume, bone mineral density, disc quality and pedicle involvement. Receiver-operator curves (ROC) and Hosmer-Lemeshow tests (HLT) were used to determine goodness of fit.of findings: Lytic metastases were identified in 72 patients, yielding a total of 92 vertebrae (maximum 2 per patient): 21 were fractured (23%, 4 wedge,17 burst) and 71 were intact (77%). Burst fracture prediction using VBN was found to have a specificity, sensitivity and confidence interval of 1 (ROC and HLT) at a threshold of 5.22 (Fig. 1). Burst fracture prediction using VHN and TS were also strong with ROC/HLT values of 0.992/0.873 and 0.988/0.749, respectively. Because the model is based on the mechanics of burst fracture, it is not predictive of wedge fracture risk.Relationship between findings and existing knowledge: Previous biomechanical analyses of metastatic spinal stability have not modeled the mechanism of burst fracture, thus limiting their predictive ability. Retrospective radiographic studies have shown tumor size and pedicle involvement to increase the risk of fracture in the metastatic spine. However, such methods based on the maximum cross-sectional area of the tumor have not yielded good specificity or clear threshold values as compared with the three-dimensional quantifications used in this study.Overall significance of findings: The VBN model exhibited excellent (100%) predictive ability for burst fractures in metastatically involved vertebrae providing useful clinical information for prophylactic decision making. Although more extensive prospective study is needed, these retrospective study results support the wider implementation of biomechanically based fracture risk prediction tools for use in clinically assessing patients with skeletal metastases.Disclosures: No disclosures.Conflict of interest: No conflict.

Long-term outcome of anterior decompression and spinal fixation after placement of the Wellesley Wedge for thoracic and lumbar spinal metastasis.

The authors assessed the long-term results of anterior decompressive and vertebral body reconstructive surgery in which the Wellesley Wedge was applied in patients with metastatic spinal lesions over the life span of these individuals. The authors performed a retrospective review of the outcome of 27 consecutively treated patients who underwent surgery for thoracic or lumbar spine metastases. Decompressive surgery was performed via an anterior thoracotomy and/or retroperitoneal approach depending on the level of the lesion. The spine was reconstructed using a U-shaped plate with an interposed methylmethacrylate strut known as the Wellesley Wedge. Thirty percent of patients suffered medical complications whereas 22% experienced postoperative improvement, as reflected by an improved Frankel grade. Used in patients with a variety of primary tumor types, a spectrum of ages and neurological status, and extensive preoperative osseous spinal involvement and deformity, the Wellesley Wedge resulted in spinal stability for the duration of patients' lives in 92%. In this series the patient selection process for surgery was a challenge yet to be solved; however, considering the durability of the Wellesley Wedge itself, the authors will continue to use it in selected patients.

Outcome after limited posterior surgery for thoracic and lumbar spine metastases.

The efficacy of 'limited posterior surgery' for metastases in the thoracic and lumbar spine was studied prospectively in 51 patients (32 men and 19 women, mean age 64 years). The most common primary tumors were prostate, breast, and renal carcinoma, 37 patients had metastases in the thoracic spine and 14 in the lumbar spine. Indications for surgery were severe pain or neurologic deficit. Of the 46 patients with neurologic symptoms, 25 were unable to walk. Surgery was confined to direct or indirect decompression and stabilization with a pedicle screw fixator over few segments as possible. Pain, as well as a variety of functional performance parameters and residential status were registered preoperatively and after surgery at 3, 6, 9, and 12 months, and at 6-monthly intervals thereafter. Pain was rated by the patient on a Visual Analog Scale, and functional performance was assessed with the Eastern Co-operative Oncology Group (ECOG) Performance Status Scale. We had no perioperative neurologic deterioration or death. Nineteen of the 25 nonambulatory patients regained their walking ability. Postoperative pain relief was significant and lasting over time. Nearly half of the patients attained improvement in functional performance. The median survival was 8 months. Older age and intact postoperative walking ability were positive factors for survival.

Surgical palliation of symptomatic spinal metastases.

Spinal metastases are common in malignant disease. For selected patients with severe pain or neurological dysfunction, surgical treatment offers valuable palliation. During the last few years, we have treated between 100 and 120 patients annually with spinal metastases at the Department of Orthopedics, Uppsala University Hospital, Uppsala, Sweden. A detailed preoperative analysis is mandatory for optimal patient selection. Preoperative embolization of spinal metastases of renal cell carcinoma minimizes the peroperative blood loss. Most cervical spinal metastases are best treated via an anterior approach with vertebral body resection and primary reconstruction of the anterior column. Most thoracic or lumbar spinal metastases are best treated via a posterior approach with decompression and stabilization, using a transpedicular fixation device. However, patients with an expected survival exceeding 6-12 months, a secondary reconstruction of the anterior column should be considered.

Solitary spinal cord metastasis of Wilms' tumor

Wilms' tumor metastasis to the spinal cord is very rare at any age. We recently encountered a case of a 4-year-old girl, who had a solitary lumbar spinal cord metastasis about 1 year following the intial nephrectomy and an incomplete course of chemotherapy for a stage I Wilms' tumor. The patient recovered uneventfully after decompressive laminectomy, removal of the extradural spinal cord tumor, adjuvant chemotherapy, and radiotherapy according to the National Wilms' Tumor Study (NWTS)-IV protocol.

Reduction of spinal metastases after preemptive irradiation in prostatic cancer

For this study, 136 patients treated at Stanford University Hospital for prostatic cancer between 1971 and 1980 were selected for review. The patients had received no prior therapy, and had no evidence of bone metastases at time of radiation treatment based on radiographic studies and bone scan. Of this group, 71 patients received extended-field irradiation (paraaortic and pelvic fields), and 65 patients received pelvic irradiation. The pelvic field was treated to 50 Gy and the paraaortic field received 45 Gy to 60 Gy. All patients subsequently underwent routine follow-up examinations and studies at Stanford University Hospital: 1,513 follow-up X rays, bone scans, and CT-scans were analyzed for site-specific recurrence. The follow-up ranged from 14 months to 16 yrs from the time of initial treatment, with a mean follow-up of 7 yrs. Lower extremities and ribs were found to be the most common sites of bone metastases. Irradiation of the lumbar spine to a dose of 35 to 60 Gy, coincidental to irradiation of the paraaortic lymph nodes prevented or delayed the development of lumbar spine metastases. The potential mechanism and clinical implications are discussed.

高カルシウム血症および白血球増多症を伴った舌がんの１症例 その発症機序について

Hypercalcemia and leukocytosis are paraneoplastic syndromes occurring in association with malignant diseases but are uncommon in head and neck cancers. In the present paper, we report a clinical cousrse of a patient with tongue cancer accompanying with not only hypercalcemia but leukocytosis. We also describe the results of experiments in which we studied the mechanisms involved in pathogenesis of hypercalcemia and leukocytosis.A 40-year-old man was seen in February, 1982 with a 2.1×1.8×1.2 squamous cell carcinoma (T2N0M0) on the right side of his tongue. He received irradiation and chemotherapy first and then a resection of his tongue, jaw and neck 11 months later. He remained well almost for 6 months but was readmitted to the hospital with the complaint of severe back pain. Computed tomography film demonstrated a bony metastasis in third or fourth lumbar spine. At that time, his serum calcium level was 16 mg/dl and white blood cell count was 18, 000/mm3. A hypocalcemic hormone calcitonin failed to reverse serum calcium level. Serum levels of calcium-elevating hormones including parathyroid hormone, active metabolite of vitamin D3 and prostaglandin E3 determined by radioimmunoassay were all within normal range.His serum serially purified by ultrafiltration, diafiltration and gel chromatography showed marked bone resorbing activity and colony stimulating activity. Peak activities of bone resorption and colony stimulation were eluted respectively at a molecular weight of approximately 20, 000 and 30, 000 dalton on Sephadex G-100 column. These activities were not detected in sera of other patients with cancer or acute inflammation and of normal individuals.It was suggested that these activities found in the serum of the patients reported here might be responsible for the hypercalcemia and leukocytosis.

Intraspinal Metastasis of Neuroblastoma — Report of a Case Detected at Autopsy —

Metastasis to the brain or spinal cord parenchyma is extremely rare in cases of neuroblastoma. We present a 3-year-7-month-old boy with neuroblastoma, stage IV, with intraspinal metastasis. He had no neurologic manifestation except incontinentia urinae and ataxia at the terminal stage. His cranial computed tomography scan showed high density areas in both cerebellar hemispheres which seemed to be distant metastatic masses. At autopsy, the metastases in the cerebellum were found to be due to dural infiltration but in the spinal cord parenchyma of the lumbar spine metastases were detected macroscopically. There were multiple distant metastatic areas near the roots, anterior and posterior. The neuroblastoma seemed to have spread along the roots by direct invasion from the meninges. In the future, the number of patients with metastasis into the brain or spinal cord parenchyma will increase because patients with progressive disease could live for a long time as a result of intensive chemotherapy. Observation of these cases will be helpful to clarify the routes of metastasis to these areas.