Spinal Metastases In Patients Research Articles

Asymmetrical vertebral collapse from spinal metastasis in lower thoracic and lumbar spine.

The purpose of this study was to investigate the differences between spinal metastasis and osteoporotic compression fractures on plain X-ray images, focusing on asymmetrical vertebral collapse and fracture level. This study included 180 patients with pathological collapse from spinal metastasis (188 vertebrae) who were treated at our institution and 70 patients (92 vertebrae) with osteoporotic compression fractures. Anteroposterior X-ray images of the lower thoracic and lumbar spine were evaluated for asymmetrical collapse deformity. Asymmetrical collapse was found in 134 vertebrae (71.3%) with metastasis, and in 20 osteoporotic vertebrae (21.7%); this difference was significant (p<0.0001). The asymmetrical collapse angle in spinal metastasis patients ranged from 0 to 18°, with a mean of 7.0 and a standard deviation (SD) of 4.5. In contrast, the asymmetrical collapse angle in patients with osteoporotic fractures ranged from 0 to 13°, with a mean of 3.1 and a SD of 2.8. The difference in collapse angle between the two groups was statistically significant (p<0.001). The cutoff value to suspect spinal metastasis was determined to be 5° or more (sensitivity 0.67, specificity 0.74). Fracture at Th10 or below L3 was found in 20.2% of spinal metastasis patients; only 3% of osteoporotic fractures occurred at these levels. Asymmetrical collapse with an angle of 5° or more and fractures at atypical levels on plain radiographs can be useful clues to spinal metastasis.

Re-irradiation stereotactic body radiotherapy for spinal metastases: a multi-institutional outcome analysis.

OBJECTIVE This study is a multi-institutional pooled analysis specific to imaging-based local control of spinal metastases in patients previously treated with conventional external beam radiation therapy (cEBRT) and then treated with re-irradiation stereotactic body radiotherapy (SBRT) to the spine as salvage therapy, the largest such study to date. METHODS The authors reviewed cases involving 215 patients with 247 spinal target volumes treated at 7 institutions. Overall survival was calculated on a patient basis, while local control was calculated based on the spinal target volume treated, both using the Kaplan-Meier method. Local control was defined as imaging-based progression within the SBRT target volume. Equivalent dose in 2-Gy fractions (EQD2) was calculated for the cEBRT and SBRT course using an α/β of 10 for tumor and 2 for both spinal cord and cauda equina. RESULTS The median total dose/number of fractions of the initial cEBRT was 30 Gy/10. The median SBRT total dose and number of fractions were 18 Gy and 1, respectively. Sixty percent of spinal target volumes were treated with single-fraction SBRT (median, 16.6 Gy and EQD2/10 = 36.8 Gy), and 40% with multiple-fraction SBRT (median 24 Gy in 3 fractions, EQD2/10 = 36 Gy). The median time interval from cEBRT to re-irradiation SBRT was 13.5 months, and the median duration of patient follow-up was 8.1 months. Kaplan-Meier estimates of 6- and 12-month overall survival rates were 64% and 48%, respectively; 13% of patients suffered a local failure, and the 6- and 12-month local control rates were 93% and 83%, respectively. Multivariate analysis identified Karnofsky Performance Status (KPS) < 70 as a significant prognostic factor for worse overall survival, and single-fraction SBRT as a significant predictive factor for better local control. There were no cases of radiation myelopathy, and the vertebral compression fracture rate was 4.5%. CONCLUSIONS Re-irradiation spine SBRT is effective in yielding imaging-based local control with a clinically acceptable safety profile. A randomized trial would be required to determine the optimal fractionation.

Effect of Spinal Fixation in Rabbits With Metastatic Tumor Using a Novel Spinal Fusion Model

An experimental assessment of the impact of spinal stabilization on metastasis growth using a rabbit model. To investigate the influence of spinal stabilization on the growth of metastatic spinal tumors in rabbits using a novel method of spinal fusion. For spinal metastasis patients, gait disturbances caused by back pain or paraplegia correlates with their prognosis. Palliative surgeries are good options for some patients; however, the appropriate timing and method of spinal surgery remains controversial. The biomechanical properties of a novel spinal fixation model with a locking plating system were first examined on the L2-L4 fixed vertebrae of 18 Japanese white rabbits. Biomechanical and radiographic examinations were performed at 0, 4, and 8 weeks as compared with controls. After this, another 31 rabbits were then inoculated with VX2 carcinoma cells into the L3 vertebral body and divided into fixation (N=16) and sham (N=15) groups to assess the impact of spinal stabilization on tumor growth. The time to paraplegia, and tumor cell growth and proliferation were evaluated by rabbit behavior, computed tomography, myelogram, and cell proliferation marker (MIB-1 index). In the biomechanical loading test, fixed segments showed one eighth of the range of motion and 15 times bending stiffness as compared with controls at each timepoint. No pathologic fractures were observed in the rabbits inoculated with VX2 carcinoma cells before paraplegia, and there was no difference in the time to paraplegia between the fixation and sham groups (26.7 and 28 d, respectively). Similarly, no differences were observed in osteolytic area expansion or tumor cell proliferation (MIB-1 index; 38.1% and 38.0%, respectively). Our locking plate fixation of rabbit spines exhibited sufficient biomechanical properties. Spinal fixation had little influence on the growth of the aggressive carcinoma and the time to paraplegia. However, further investigation is needed to determine the influence of spinal stabilization on slow-growing tumors.

Features of primary organ and prognosis of spinal metastases in patients with spine related initial symptoms

Features of primary organ and prognosis of spinal metastases in patients with spine related initial symptoms

Minimally Invasive Spinal Stabilization Using Fluoroscopic-Guided Percutaneous Screws as a Form of Palliative Surgery in Patients with Spinal Metastasis.

Study DesignProspective cohort study.PurposeTo report the outcome of 50 patients with spinal metastases treated with minimally invasive stabilization (MISt) using fluoroscopic guided percutaneous pedicle screws with/without minimally invasive decompression.Overview of LiteratureThe advent of minimally invasive percutaneous pedicle screw stabilization system has revolutionized the treatment of spinal metastasis.MethodsBetween 2008 and 2013, 50 cases of spinal metastasis with pathological fracture(s) with/without neurology deficit were treated by MISt at our institution. The patients were assessed by Tomita score, pain score, operation time, blood loss, neurological recovery, time to ambulation and survival.ResultsThe mean Tomita score was 6.3±2.4. Thirty seven patients (74.0%) required minimally invasive decompression in addition to MISt. The mean operating time was 2.3±0.5 hours for MISt alone and 3.4±1.2 hours for MISt with decompression. Mean blood loss for MISt alone and MISt with decompression was 0.4±0.2 L and 1.7±0.9 L, respectively. MISt provided a statistically significant reduction in visual analog scale pain score with mean preoperative score of 7.9±1.4 that was significantly decreased to 2.5±1.2 postoperatively (p=0.000). For patients with neurological deficit, 70% displayed improvement of one Frankel grade and 5% had an improvement of 2 Frankel grades. No patient was bed-ridden postoperatively, with the average time to ambulation of 3.4±1.8 days. The mean overall survival time was 11.3 months (range, 2–51 months). Those with a Tomita score <8 survived significantly longer than those a Tomita score ≥8 with a mean survival of 14.1±12.5 months and 6.8±4.9 months, respectively (p=0.019). There were no surgical complications, except one case of implant failure.ConclusionsMISt is an acceptable treatment option for spinal metastatic patients, providing good relief of instability back pain with no major complications.

Dosimetric Study on Feasibility of Using Pre QA’ed Universal SBRT Plan for the First Fraction of Emergency Treatment for Spine Metastasis Patients

Dosimetric Study on Feasibility of Using Pre QA’ed Universal SBRT Plan for the First Fraction of Emergency Treatment for Spine Metastasis Patients

Clinical efficacy of percutaneous vertebroplasty combined with intensity-modulated radiotherapy for spinal metastases in patients with NSCLC.

ObjectiveThis study aimed to evaluate the safety and efficacy of percutaneous vertebroplasty (PVP) combined with intensity-modulated radiotherapy (IMRT) for metastatic lesions of patients with non-small-cell lung cancer (NSCLC) at centrum vertebrae.MethodsA total of 39 patients with spinal metastatic NSCLC (stage IV) were treated with PVP followed by IMRT (30 Gy/10F/2 W) for metastatic lesion at centrum vertebrae under local anesthesia. Retrospective analysis was done with medical records and radiological data. The change of visual analog scale (VAS), activities of daily living, and kyphotic angle was measured preoperatively. The presence of complications was assessed preoperatively (baseline) at 24 hours, 1 week, and 1, 3, 6, 12, and 24 months postoperatively, or until the patient died or was lost to follow-up. Survival was assessed in the group.ResultsA total of 39 consecutive patients were successfully treated with PVP via a translateral approach and IMRT. Their mean VAS score decreased from 7.93±1.09 preoperatively to 4.14±1.15 by the 24-hour postoperative time point and was 3.92±1.23 at 1 week, 4.27±1.93 at 1 month, 3.24±1.35 at 3 months, 2.27±0.96 at 6 months, and 2.59±1.55 at 12 months after the procedure. The mean VAS score at all of the postoperative time points was decreased significantly from the preoperative baseline score (P<0.05). Activities of daily living evaluation showed that the patients had a significantly high life quality after the combined approach (50.9±11.7 vs 82.3±9.9, P<0.05). No severe complications were observed. Mild complications included two cases (5.13%) of asymptomatic cement leakage into the epidural space and one case (2.56%) of paravertebral leakage. Median survival time was extended to 13 months.ConclusionThe safety and efficacy of PVP combined with IMRT in patients with NSCLC with metastatic lesions at centrum vertebrae and the ability to prevent the diseased vertebrae from further deformation and tumor infiltration into the vertebral body were demonstrated. PVP combined with IMRT should be the optimal technique for treatment of vertebral compression pain resulting from spinal metastatic NSCLC.

Improved patient selection by stratified surgical intervention: Aarhus Spinal Metastases Algorithm

Background contextChoosing the best surgical treatment for patients with spinal metastases remains a significant challenge for spine surgeons. There is currently no gold standard for surgical treatments. The Aarhus Spinal Metastases Algorithm (ASMA) was established to help surgeons choose the most appropriate surgical intervention for patients with spinal metastases. PurposeThe purpose of this study was to evaluate the clinical outcome of stratified surgical interventions based on the ASMA, which combines life expectancy and the anatomical classification of patients with spinal metastases to inform surgical decision making. Study design/SettingThis is a retrospective study based on a prospective database. Patient sampleA consecutive series of 515 spinal metastatic patients who underwent surgically treatment from December 1992 to June 2012 in Aarhus University Hospital were included prospectively and analyzed in detail retrospectively. Outcome measuresSurvival time after surgery was determined for all patients. Neurological function was assessed using the Frankel score preoperatively and postoperatively (at the time of discharge). Complete outcome data were retrieved in 97.5% of this cohort. MethodsPatients with spinal metastases were identified from an institutional database that prospectively collected data since 1992. Survival status data were obtained from a national registry. Neurological function was determined from the same institutional database or local Electronic Patient Journal system. Surgeons evaluated and classified patients into five surgical groups preoperatively by using the revised Tokuhashi score (TS) and the Tomita anatomical classification (TC). ResultsThe overall median survival time of the cohort was 6.8 (95% confidence interval: 6.1–7.9) months. The median survival times in the five surgical groups determined by the ASMA were 2.1 (TS 0–4, TC 1–7), 5.1 (TS 5–8, TC 1–7), 12.1 (TS 9–11, TC 1–7 or TS 12–15, TC 7), 26.0 (TS 12–15, TC 4–6), and 36.0 (TS 12–15, TC 1–3) months. The 30-day mortality rate was 7.5%. Postoperative neurological function was maintained or improved in 469 patients (92.3%). Overall reoperation rate was 13.5%, commonly because of postoperative hematoma and new limb weakness. ConclusionsThe ASMA recommends at least two surgical options for a particular patient by determining the preoperative life expectancy and anatomical classification of the spinal metastases. This algorithm could help spine surgeons to discriminate the risks of surgeries. The ASMA provides a tool to guild surgeons to evaluate the spinal metastases patients, select potential optimal surgery, and avoid life-threatening risks.

Surgical treatment of 21 patients with spinal metastases of differentiated thyroid cancer

Background Differentiated thyroid cancer (DTC) is a common primary cancer for spinal metastases (SM). The treatments for DTC spinal metastases (SM) have evolved from simple surgery and radiotherapy to a multidisciplinary comprehensive therapeutic strategy of combined spinal surgery, general surgery, radiotherapy, nuclear medicine and endocrinology. The purpose of this study was to discuss the efficacy and prognosis associated with different surgical treatments of SM patients with DTC. Methods A total of 21 consecutive patients with SM of DTC that were treated between 1999 and 2013 were studied. Biopsy was routinely performed to achieve the pathological diagnosis before treatment. Three patients underwent total spondylectomy intralesionally or piecemeally, and 18 had curettage. Postoperative recurrence and survival times were analyzed by the Kaplan-Meier methods. Results Nineteen patients (90%) had an average of 42.7 months (range, 7-170 months) follow-up. The median visual analogue scale for pain reduced from 5 points to 1 point (P &lt;0.01), and the median Karnofsky performance score increased from 70 to 90 points after surgery (P &lt;0.01). Seventeen patients with neurological deficits attained improvements after surgeries, of at least one level according to the Frankel classification (P &lt;0.01). Eight patients with curettage had recurrence. Four patients died of DTC, 12 patients lived with disease, and three patients were disease-free. No significant effects on postoperative recurrence or survival were observed between surgery combined with conservative treatment, total spondylectomy, the number of bone metastases and visceral metastasis. Conclusions DTC-SM have a relatively favorable prognosis, and curettage and stabilization can effectively relieve the pain and improve the quality of life and neurological status of the patients. For patients with Tomita scores of ≤3, total spondylectomy may have better clinical outcomes. Comprehensive therapeutic strategies including surgery, radioiodine, external beam radiation therapy and embolization should be considered for most patients.

Spinal metastases due to thyroid carcinoma: an analysis of 202 patients.

Spinal metastases (SMs) due to thyroid cancer (TC) are associated with significantly reduced quality of life. The goal of this study is to analyze the clinical manifestations, presentation, and treatments of TC SMs, and to describe specific features of SMs associated with different TC types. A retrospective analysis of 202 TC SM patients treated at Medstar Washington Hospital Center (37) and collected from the literature (165) was performed. The mean age of patients with SMs was 56.9±14.7 years, and the female-to-male ratio was 2.1:1. Of all patients, 29% (28% of follicular thyroid cancer [FTC] and 37% of papillary thyroid cancer [PTC]) had SMs only. Twenty-nine percent of all patients and 54% of patients with single-site SMs had neither bone non-SMs nor solid organ metastases at the time of presentation. Thirty-five percent of patients had SMs as an initial presentation of TC. TC patients presenting with SMs had a lower rate of other bone and visceral involvement compared with patients whose SMs were diagnosed at the time of thyroid surgery or during follow-up (p<0.05). SMs were more often the initial manifestation of FTC (41% vs. 24%), while PTC SMs were more commonly diagnosed after TC diagnosis (76% vs. 59%; p<0.05). PTC SMs were more frequently diagnosed as synchronous (63% vs. 36% in FTC) versus FTC SMs that developed as metachronous metastases (64% vs. 37% in PTC; p<0.01). All FTC SMs developed within 82 (0-372) months and all PTC SMs within 35 (0-144) months (p<0.01). In FTC SMs as TC manifestation, solid organ metastases involvement was less common than in FTC SMs that were found after TC diagnosis (34% vs. 67%; p<0.01); multisite FTC SMs compared to solitary FTC SMs were associated with the development of other bone nonspinal metastases (82% vs. 30%; p<0.01) and solitary organ metastases (65% vs. 41%; p<0.01). These correlations were not observed in PTC SMs. FTC patients often had neural structure compression (myelopathy/radiculopathy; 72% vs. 36% in PTC), while PTC patients frequently were asymptomatic (38% vs. 5% in FTC; p<0.01). FTC SMs more commonly were (131)I-avid (p<0.01). FTC patients required surgery more frequently (72% vs. 55% in PTC; p<0.05). Our study reveals that a significant part of TC SMs patients have solitary spinal involvement at the time of presentation and may be considered for aggressive treatment with the intention to improve quality of life and survival. FTC SMs and PTC SMs appear to have distinct presentations, behavior, and treatment modalities, and should be categorized separately for treatment and follow-up planning.

Long-term safety and efficacy of fractionated stereotactic body radiation therapy for spinal metastases.

Patients with long life expectancy despite metastatic status might benefit from long-term local control of spinal metastases. Dose-intensified radiotherapy (RT) is believed to control tumor growth better and thus offers longer pain relief. This single-institution study reports on fractionated stereotactic body radiation therapy (SBRT) for spinal metastases in patients with good life expectancy based on performance status, extent of metastases, histology, and time to metastasis. Between 2004 and 2010, 36 treatment sites in 32 patients (median age 55 years; male 61%; median Karnofsky performance score 85) were treated with fractionated SBRT. The median treatment dose was 60 Gy (range, 48.5-65 Gy) given in a median of 20 fractions (range, 17-33); the median maximum dose to the planning risk volume for the spinal cord (PRV-SC) was 46.6 Gy. All patients suffering from pain prior to RT reported pain relief after treatment; after a median follow-up of 20.3 months, 61% of treatment sites were pain-free, another 25% associated with mild pain. In 86% of treatments, patients were free from neurological symptoms at the time of the last clinical follow-up. Acute grade 1 toxicities (CTCAE 3.0) were observed in 11 patients. Myelopathy did not occur in any patient. Radiologically controlled freedom from local progression was 92 and 84% after 12 and 24 months, respectively. Median overall survival (OS) was 19.6 months. Patient selection resulted in long OS despite metastatic disease, and dose-intensified fractionated SBRT for spinal metastases was safe and achieved long-term local tumor control and palliation of pain.

Stereotactic Body Radiotherapy (SBRT) for Spinal Metastases

The purpose of this study was to evaluate local control and survival in patients with spinal metastases who were treated with stereotactic body radiotherapy (SBRT) using a CyberKnife, with or without a prior history of irradiation, and to identify prognostic factors predicting them. Between August 2008 and November 2012, 59 spinal metastatic lesions in 39 patients were treated with SBRT. Fourteen lesions (23.7%) were re-irradiated to treat recurrence after prior radiotherapy. Patients were treated with a median radiation dose of 27 Gy (range, 18-35 Gy) in a median of three fractions (range, one to five) using the CyberKnife Xsight Spine tracking system. Median planning target volume of the 59 spinal metastatic lesions was 37.4 cm(3) (range, 0.9-301.4 cm(3)). Radiation was prescribed to the median 80% isodose line that encompassed at least 90% of the tumor volume. The revised Tokuhashi scoring system and the Tomita scoring system were adopted to predict survival of patients. Local progression was defined as tumor progression by imaging, or if other therapy such as surgery or re-irradiation was given after SBRT, as salvage treatment. The median follow-up period was 7.4 months (range, 1.1-42.5 months). Four of 59 (6.8%) lesions experienced local progression, and all of them occurred within 1-year. Two of four local progressions occurred in re-irradiated tumors, which received 21 Gy in three fractions. With respect to treatment site-specific survival (TSS), better performance status and no visceral metastases were associated with a superior outcome (p = 0.011 and p = .001, respectively). With respect to overall survival (OS), better performance status was marginally related to superior outcome (p = 0.096). The revised Tokuhashi scoring system and the Tomita scoring system predicted OS and TSS in patients treated with SBRT. Two patients developed vertebral compression fractures at 1.2 and 1.4 months after SBRT with no evidence of tumor progression. There was no radiation-induced myelopathy. SBRT with a CyberKnife is a safe and effective treatment modality to achieve local control in spinal metastases patients, including those with a previous history of conventional RT. SBRT should be considered for those patients with a relatively indolent primary tumor, good performance status, and no visceral metastases. Survival of these patients can potentially be prolonged by long-term control of spinal metastases.

Risk factors for wound infection in surgery for spinal metastasis

Wound infection rates are generally higher in patients undergoing surgery for spinal metastasis. Risk factors of wound infection in these patients are poorly understood. To identify demographic and clinical variables that may be associated with patients experiencing a higher wound infection rate. Retrospective study with prospectively collected data of spinal metastasis patients operated consecutively at a University Teaching Hospital, adult spine division which is a tertiary referral centre for complex spinal surgery. Ninety-eight patients were all surgically treated, consecutively from January 2009 to September 2011. Three patients had to be excluded due to inadequate data. Physiological measures, with presence or absence of microbiologically proven infection. Various demographic and clinical data were recorded, including age, serum albumin level, blood total lymphocyte count, corticosteroid intake, Malnutrition Universal Screening Tool (MUST) score, neurological disability, skin closure material used, levels of surgery and administration of peri-operative corticosteroids. No funding was received from any sources for this study and as far as we are aware, there are no potential conflict of interest-associated biases in this study. Higher probabilities of infection were associated with low albumin level, seven or more levels of surgery, use of delayed/non-absorbable skin closure material and presence of neurological disability. Of these factors, levels of surgery were found to be statistically significant at the 5% significance level. Risk of infection is high (17.9%) in patients undergoing surgery for spinal metastasis. Seven or more vertebral levels of surgery increase the risk of infection significantly (p<0.05). Low albumin level and presence of neurological disability appear to show a trend towards increased risk of infection. Use of absorbable skin closure material, age, low lymphocyte count, peri-operative administration of corticosteroids and MUST score do not appear to influence the risk of infection.

Percutaneous Vertebroplasty Combined with Zoledronic Acid for the Treatment of Painful Osteolytic Spinal Metastases in Patients with Breast Cancer

To assess retrospectively the efficacy and safety of percutaneous vertebroplasty (PVP) combined with zoledronic acid (ZA) for the treatment of painful osteolytic spinal metastases from breast cancer. PVP was performed in 43 patients with breast cancer and painful osteolytic spinal metastases; 126 vertebrae were treated. The patients subsequently received 4 mg ZA via a 15-minute intravenous infusion every 4 weeks for 12 months. Pain and quality of life (QoL) were assessed using a visual analog scale (VAS) and Karnofsky performance scale (KPS), respectively, 24 hours before PVP and 24 hours, 1 month, 3 months, 6 months, and 12 months after PVP. Skeletal-related events (SREs) were assessed for 12 months following the intervention. The mean VAS scores decreased significantly from 7.6 ± 1.9 at 24 hours before PVP to 3.6 ± 1.4 at 24 hours, 2.0 ± 1.5 at 1 month, 2.8 ± 1.6 at 3 months, 3.1 ± 0.8 at 6 months, and 2.5 ± 0.9 at 12 months after the intervention (P < .05). KPS scores increased significantly after the combination treatment (P < .05). Compared with previous studies without PVP or ZA treatment, this patient group had a lower incidence of SREs. No major complications were observed. PVP combined with ZA was shown to be a highly effective and safe combination therapy to relieve pain and improve QoL in patients with osteolytic spinal metastases from breast cancer. The combination therapy also prevented the occurrence of SREs.

Tokuhashi Scoring System has limited applicability in the majority of patients with spinal cord compression secondary to vertebral metastasis

Spine is the primary bone site affected by systemic metastasis. Although there are scales that attempt to manage these patients, their real applicability is unknown. The Tokuhashi Scoring System (TSS) is a widely used prognostic tool. At the time of treatment, the data necessary to complete TSS may be incomplete, making its application impossible. Objective To evaluate the number of TSS scores completed by the time the clinical therapeutic decision was made. Methods From July 2010 to January 2012, we selected patients who were diagnosed with spinal metastases. Results Sixty spinal metastasis patients (21 female, 39 male) were evaluated between July 2010 and January 2012. At the time of the treatment decision, only 25% of the patients had completed the TSS items. Conclusion In the majority of patients with vertebral metastasis, TSS variables cannot be applied.

Reliving refractory pain of spinal metastasis patients with radiofrequency ablation through transforaminal endoscopy

To explore the short-term outcomes of radiofrequency ablation treatment of bone metastasis. Between November 2011 and November 2012, a total of 18 cases were retrospectively reviewed. They underwent resection of bone metastasis with radiofrequency ablation through transforaminal endoscopic spine system. According to the Tomita classification system, the classifications were type 5 (n = 8), type 6 (n = 4) and type 7 (n = 6). There were 8 males and 10 females with a median age of 52.1 (32-76) years. The primary lesions were breast cancer (n = 5), carcinoma of prostate (n = 3), digestive cancer (n = 4), thyroid carcinoma (n = 2)and lung cancer (n = 4). And two cases had pathologic fracture. The operative duration was 118 (90-180) min and blood loss volume 30.6 (10-60) ml. All incisions achieved excellent healing.One case of pneumonia recovered with antibiotic. The postoperative visual analogue scale (VAS) scores were 2.4 ± 0.4, 2.6 ± 0.6, 3.0 ± 0.3 and 2.8 ± 0.7. Radiofrequency ablation through transforaminal endoscopy may be a safe and efficacious option for refractory pain with bone metastasis, especially for those with uncontrolled pain. This procedure is mini-invasive and causes less bleeding.

Comparison of deliverable IMRT and VMAT for spine metastases using a simultaneous integrated boost

To effectively treat spine metastases, significant dose must be delivered to regions surrounding the spinal cord. We present a study comparing both step-and-shoot intensity modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT) techniques to deliver a concomitant hypofractionated prescription dose to the diseased region and to the involved vertebrae. Seven-field IMRT and a single arc VMAT were inversely planned on five (two cervical and three thoracic) spinal metastatic patients. Planning target volumes PTVm (macroscopic) and PTVe (elective involved vertebrae) and associated organs at risk were localised. Mean doses of 35 Gy to PTVm and 20 Gy to PTVe were prescribed in five fractions. Dose statistics, estimated delivery time and results of verification using Delta(4) (ScandiDos, Uppsala, Sweden) were compared. Deliverable plans were achieved with both IMRT and VMAT. The coverage to PTV was similar for both IMRT and VMAT (p=0.5) and the dose to the regions adjacent to the spinal cord was 1% higher with VMAT (p=0.04). The mean delivery time for VMAT was 3.5 min compared with 10.5 min for IMRT. Fewer monitor units were required to deliver IMRT than to deliver VMAT. The median (range) percentage of measured points with a γ-index <1 with 3%/3 mm was 100 (99.9-100)% for IMRT and 100 (88.5-100)% for VMAT. Both VMAT and IMRT can deliver the concomitant hypofractionated regime proposed, and both offer different benefits in dose delivery. IMRT is currently preferred for its superior pre-treatment verification results and shorter planning times. This study explores the feasibility of delivering tumouricidal doses of radiation to metastatic spine disease in the vicinity of the spinal cord.

Role of Intraoperative Red Cell Salvage and Autologus Transfusion in Metastatic Spine Surgery: A Pilot Study and Review of Literature

Study DesignProspective cohort study.PurposeThere has been no research examining the use of intraoperative cell salvage during metastatic spinal surgery. The present work is a pilot study investigating the role of cell salvage during metastatic spine surgery.Overview of LiteratureThere is no spinal literature about role of cell salvage and autologus transfusion in metastatic spinal cancer.MethodsSixteen spinal metastases patients who received red cell salvage using a leucocyte depletion filter were enrolled. Of these, ten patients who received salvaged blood transfusion were included in the final analysis. Data collection involved looking at the case notes, operating room records and the prospectively updated metastatic spinal cancer database maintained in the spinal department. Cell salvage data was recovered from the central cell salvage database maintained in the anesthetic department.ResultsAmount of salvaged blood ranged from 120 to 600 mL (average, 318 mL). The average drop in hemoglobin was 1.65 units (range, 0.4-2.7 units). Three patients (30%) required postoperative allogenic blood transfusion. The average follow up was 9.5 months (range, 6-6 months). One patient developed new lung metastasis, at seven months. No patient developed new liver metastases. Preoperatively, six patients had diffuse skeletal metastases. Of this subgroup, three developed new skeletal metastases. No cases showed any wound related problems in the postoperative period.ConclusionsIn our study transfusion of intraoperatively salvaged blood did not result in disseminated metastatic cancer. We would suggest that red cell salvage might have a role during metastatic spine surgery.

Pain and quality of life in patients undergoing radiotherapy for spinal metastatic disease treatment.

BackgroundRadiotherapy is an important tool in the control of pain in patients with spinal metastatic disease. We aimed to evaluate pain and of quality of life of patients with spinal metastatic disease undergoing radiotherapy with supportive treatment.MethodsThe study enrolled 30 patients. From January 2008 to January 2010, patients selection included those treated with a 20 Gy tumour dose in five fractions. Patients completed the visual analogue scale for pain assessment and the SF-36 questionnaire for quality of life assessment.ResultsThe most frequent primary sites were breast, multiple myeloma, prostate and lymphoma. It was found that 14 spinal metastatic disease patients (46.66%) had restricted involvement of three or fewer vertebrae, while 16 patients (53.33%) had cases involving more than three vertebrae. The data from the visual analogue scale evaluation of pain showed that the average initial score was 5.7 points, the value 30 days after the end of radiotherapy was 4.60 points and the average value 6 months after treatment was 4.25 points. Notably, this final value was 25.43% lower than the value from the initial analysis. With regard to the quality of life evaluation, only the values for the functional capability and social aspects categories of the questionnaire showed significant improvement.ConclusionRadiotherapy with supportive treatment appears to be an important tool for the treatment of pain in patients with spinal metastatic disease.

Prevalence of Known and Unknown Primary Tumor Sites In Spinal Metastasis Patients

Study Design: A retrospective study.Objectives: Three objectives have been designated for this study: (1) to determine the prevalence of identifiable and non-identifiable primary tumor sites in patients with spinal metastasis, (2) to identify the most common site of the known primary tumor sites, and (3) to identify the factors associated with survival time.Summary of Background Data: The spine is the third most common metastatic site for several primary visceral carcinomas. The primary tumor site could not be identified in 15% to 20% of patients who had been diagnosed of with a skeletal metastasis. Most of the previous studies on skeletal metastasis have not been limited to spinal metastasis alone.Methods: Between January 2007 and July 2011 reviews were done for 82 patients with spinal metastasis who had not received a previous diagnosis of carcinoma. The assessment parameters included the following: general demographic data, Karnofsky score, Frankel score, number of spinal vertebra affected, region of the spine affected by metastasis, other skeletal metastasis site, visceral metastasis, known or unknown primary sites of metastasis, histological cell type of metastasis, and the survival period. The log-rank test and Cox proportional hazard model were used to study the survival analysis.Results: Of the 82 patients included in the study, 56 were male. The mean age was 57 years. 86.6% had a known primary carcinoma site while the remaining 13.4% had none. The two most common known carcinoma sites were the lung and biliary systems. Among the 11 unknown primary sites, the most common histological finding was adenocarcinoma. The mean survival period was 8.7 ± 11.7 months. The survival analysis revealed two statistically significant factors: the primary tumor site’s aggressiveness (P<0.005) and the presence of visceral metastasis (P<0.05).Conclusion: The prevalence of identifiable primary site was 86.6% and the most common site was the lungs followed by the biliary system. The primary carcinoma site’s aggressiveness and the presence of visceral metastasis were the factors associated with patient survival.