Spinal Metastases Research Articles

Radiomics model based on MRI to differentiate spinal multiple myeloma from metastases: A two-center study

PurposeSpinal multiple myeloma (MM) and metastases are two common cancer types with similar imaging characteristics, for which differential diagnosis is needed to ensure precision therapy. The aim of this study is to establish radiomics models for effective differentiation between them. MethodsEnrolled in this study were 263 patients from two medical institutions, including 127 with spinal MM and 136 with spinal metastases. Of them, 210 patients from institution I were used as the internal training cohort and 53 patients from Institution II were used as the external validation cohort. Contrast-enhanced T1-weighted imaging (CET1) and T2-weighted imaging (T2WI) sequences were collected and reviewed. Based on the 1037 radiomics features extracted from both CET1 and T2WI images, Logistic Regression (LR), AdaBoost (AB), Support Vector Machines (SVM), Random Forest (RF), and multiple kernel learning based SVM (MKL-SVM) were constructed. Hyper-parameters were tuned by five-fold cross-validation. The diagnostic efficiency among different radiomics models was compared by accuracy (ACC), sensitivity (SEN), specificity (SPE), area under the ROC curve (AUC), YI, positive predictive value (PPV), negative predictive value (NPY), and F1-score. ResultsBased on single-sequence, the RF model outperformed all other models. All models based on T2WI images performed better than those based on CET1. The efficiency of all models was boosted by incorporating CET1 and T2WI sequences, and the MKL-SVM model achieved the best performance with ACC, AUC, and F1-score of 0.862, 0.870, and 0.874, respectively. ConclusionsThe radiomics models constructed based on MRI achieved satisfactory diagnostic performance for differentiation of spinal MM and metastases, demonstrating broad application prospects for individualized diagnosis and treatment.

Abstract 2396: Tumor treating fields (TTFields) for spinal metastasis: Clinical trial concept for use of conductive implants as waveguides to enhance TTFields strength

Abstract Tumor treating fields (TTFields) is a FDA-approved electric fields-based therapy for glioblastoma (GBM) and malignant pleural mesothelioma. We describe a novel approach to increase the strength and therapeutic effect of TTFields at vertebral tumor targets, using spinal implants as electrically-conductive waveguides. In vivo anti-cancer efficacy is achieved with TTFields strength >1 V/cm. If the tumor is surrounded by tissues of lower conductivity (e.g., the skull in the case of GBM), then the TTFields strength reaching the tumor is decreased. Surgical treatment of radiation-refractory spinal metastases is difficult and provides a short-term benefit at the expense of a lengthy recovery. Such resections require bone removal that disrupts the spinal stability, necessitating reconstruction with titanium (Ti) pedicle screw constructs that are electrically conductive. We theorize that astute placement of Ti hardware in the proximate spinal levels post-resection would have a waveguiding effect of electrical current from the surrounding muscle towards the tumor. This would in turn boost TTFields strength achieved around the resection cavity, decreasing the chances of tumor recurrence. Bomzon et al. described a computational model of the distribution of TTFields in a realistic human torso. The simulation demonstrated that a TTFields strength of 3 V/cm can be achieved, which is approximately 3-fold greater than what is achieved in the brain parenchyma in the context of TTFields for GBM. In a more generic simulation using a 0.5 × 100 mm waveguide targeting a tumor deeper in the torso (480 mA), we found 21.8 vs. 61.2 cm3 volumes achieving ≥ the 1.0 V/cm efficacy floor, without and with the waveguide, respectively, a 2.8-fold increase. At a higher amplitude (550 mA) and stronger TTFields strength threshold of ≥1.5 V/cm, a negligible volume was attained with no waveguide (0.1 cm3), whereas a volume of 17.6 cm3 was attained around the tip of the waveguide when present. Based on compelling pre-clinical data, a prospective clinical trial is being designed in which patients with radiation-refractory spinal metastasis from any number of primary sites will undergo resection. Next, primary cultures of their tumor cells will be made and evaluated for the TTFields frequency that maximizes cell death on a per-patient basis. Patients will then undergo postoperative local TTFields therapy ± systemic therapy. The primary endpoint will be safety and efficacy of such an approach, with future aims focusing on local control rates. The application of TTFields as an adjunct to surgery may offer a new therapeutic option for patients with spinal metastasis who would otherwise not be considered surgical candidates. Similarly, waveguides may be used throughout the head and body to increase TTFields efficacy. Citation Format: Claudio E. Tatsui, Kristen W. Carlson, Chirag B. Patel. Tumor treating fields (TTFields) for spinal metastasis: Clinical trial concept for use of conductive implants as waveguides to enhance TTFields strength [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 2396.

Abstract 3339: TTFields for the management of spinal metastases in in vitro and in vivo models

Abstract Spine metastases often affect cancer patients, leading to significant morbidity and mortality. Their prevalence has increased over time due to the progressive improvements in cancer management which led to a longer survival of these individuals. Radiation therapy is the mainstay treatment for local control of these lesions, with surgery reserved for selected cases (e.g., spinal instability, neurological deficits secondary to neural compression requiring urgent decompression, separation surgery). Chemotherapy addresses the diffusely metastatic spread. However, when spinal metastases progress despite using all the appropriate available treatment, there follows a progressive decline in function and further treatment options are limited, highlighting the need for development of novel therapies. Tumor treating fields (TTFields) has demonstrated to impair tumor cell replication and are influenced by surrounding tissue, such as bone (presents non-conductive properties). Our goal was to investigate the effects of TTFields in in vitro and in vivo spinal metastasis models. We hypothesize that the deposition of TTFields is increased in bone, and this would ultimately result in vertebral metastasis growth suppression. A computational model using a simulated spine resection cavity with metallic hardware was used to investigate the TTFields intensity in various tissues. For in vitro studies, luciferase tagged KRIB osteosarcoma and A549 lung adenocarcinoma cell lines were cultured in demineralized human bone graft. These were treated with TTFields and cell viability was quantified. In vivo assays were performed using a previous validated murine orthotopic tumor model. The effects of TTFields in these animals were monitored with imaging (bioluminescence and MRI) and clinical findings (progressive neurological deficits milestones that corresponds to the degree of spinal cord compression). At the end of the study, tissue was collected for histologic analysis. Sham stimulation was used for control groups. Computational simulation demonstrated an elevated TTFields intensity in the tumor-bone interface of the resected vertebral body. In all experimental models, TTFields significantly suppressed tumor cell growth. In vivo models, this effect on cell proliferation prevented tumor growth into the spinal canal, delaying, or even preventing, neurological deficits. TTFields inhibited tumor growth in three-dimensional cultures and orthotopic murine models of spinal metastases, preventing functional loss. The bony environment surrounding the tumor demonstrated to enhance the intensity of electric fields on a computational simulation, which stands as an advantage with the use of TTFields for vertebral tumors. These results provide solid evidence supporting future clinical trials investigating the effects of this novel and promising technology for the treatment of spine metastases. Citation Format: Romulo Augusto Andrade de Almeida, Daniel Ledbetter, Xizi Wu, Ariel Naveh, Chirag Patel, Queena Gonzalez, Thomas H. Beckham, Robert Y. North, Laurence Rhines, Christopher A. Alvarez-Breckenridge, Claudio E. Tatsui. TTFields for the management of spinal metastases in in vitro and in vivo models [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3339.

Tumor treating fields suppress tumor cell growth and neurologic decline in models of spinal metastases.

Spinal metastases can result in severe neurologic compromise and decreased overall survival. Despite treatment advances, local disease progression is frequent, highlighting the need for novel therapies. Tumor treating fields (TTFields) impair tumor cell replication and are influenced by properties of surrounding tissue. We hypothesized that bone's dielectric properties will enhance TTFields-mediated suppression of tumor growth in spinal metastasis models. Computational modeling of TTFields intensity was performed following surgical resection of a spinal metastasis and demonstrated enhanced TTFields intensity within the resected vertebral body. Additionally, luciferase-tagged human KRIB osteosarcoma and A549 lung adenocarcinoma cell lines were cultured in demineralized bone grafts and exposed to TTFields. Following TTFields exposure, the bioluminescence imaging (BLI) signal decreased to 10%-80% of baseline, while control cultures displayed a 4.48- to 9.36-fold increase in signal. Lastly, TTFields were applied in an orthotopic murine model of spinal metastasis. After 21 days of treatment, control mice demonstrated a 5-fold increase in BLI signal compared with TTFields-treated mice. TTFields similarly prevented tumor invasion into the spinal canal and development of neurologic symptoms. Our data suggest that TTFields can be leveraged as a local therapy within minimally conductive bone of spinal metastases. This provides the groundwork for future studies investigating TTFields for patients with treatment-refractory spinal metastases.

Clinical efficacy analysis of surgical treatment for spinal metastasis under the multidisciplinary team using the NOMS decision system combined with the revised Tokuhashi scoring system: a randomized controlled study

ObjectiveDespite advancements in spinal metastasis surgery techniques and the rapid development of multidisciplinary treatment models, we aimed to explore the clinical efficacy of spinal metastasis surgery performed by a combined NOMS decision system-utilizing multidisciplinary team and Revised Tokuhashi scoring system, compared with the Revised Tokuhashi scoring system.MethodsClinical data from 102 patients with spinal metastases who underwent surgery at three affiliated hospitals of Zunyi Medical University from December 2017 to June 2022 were analysed. The patients were randomly assigned to two groups: 52 patients in the treatment group involving the combined NOMS decision system-utilizing multidisciplinary team and Revised Tokuhashi scoring system (i.e., the combined group), and 50 patients in the treatment group involving the Revised Tokuhashi scoring system only (i.e., the revised TSS-only group). Moreover, there were no statistically significant differences in preoperative general data or indicators between the two groups. Intraoperative and postoperative complications, average hospital stay, mortality rate, and follow-up observation indicators, including the visual analogue scale (VAS) score for pain, Eastern Cooperative Oncology Group (ECOG) performance status, Karnofsky Performance Status (KPS) score, negative psychological assessment score (using the Self-Rating Anxiety Scale, [SAS]), and neurological function recovery score (Frankel functional classification) were compared between the two groups.ResultsAll 102 patients successfully completed surgery and were discharged. The follow-up period ranged from 12 to 24 months, with an average of (13.2 ± 2.4) months. The patients in the combined group experienced fewer complications such as surgical wound infections 3 patients(5.77%), intraoperative massive haemorrhage 2 patients(3.85%), cerebrospinal fluid leakage 2 patients(3.85%), deep vein thrombosis 4 patients(7.69%),and neurological damage 1 patient(1.92%), than patients in the revised TSS-only group (wound infections,11 patients(22%); intraoperative massive haemorrhage, 8 patients(16%);cerebrospinal fluid leakage,5 patients(10%);deep vein thrombosis,13 patients (26%); neurological damage,2 patients (4%). Significant differences were found between the two groups in terms of surgical wound infections, intraoperative massive haemorrhage, and deep vein thrombosis (P < 0.05). The average postoperative hospital stay in the combined group (7.94 ± 0.28 days) was significantly shorter than that in the revised TSS-only group (10.33 ± 0.30 days) (P < 0.05). Long-term follow-up (1 month, 3 months, 6 months, and 1 year postoperatively) revealed better clinical outcomes in the combined group than in the revised TSS-only group in terms of VAS scores, overall KPS%, neurological function status Frankel classification, ECOG performance status, and SAS scores.(P < 0.05).ConclusionA multidisciplinary team using the NOMS combined with the Revised Tokuhashi scoring system for spinal metastasis surgery showed better clinical efficacy than the sole use of the Revised Tokuhashi scoring system. This personalized, precise, and rational treatment significantly improves patient quality of life, shortens hospital stay, reduces intraoperative and postoperative complications, and lowers mortality rates.

Are Current Survival Prediction Tools Useful When Treating Subsequent Skeletal-related Events From Bone Metastases?

Are Current Survival Prediction Tools Useful When Treating Subsequent Skeletal-related Events From Bone Metastases?

Synchronous versus metachronous spinal metastasis: a comparative study of survival outcomes following neurosurgical treatment

PurposePatients with spinal metastases (SM) from solid neoplasms typically exhibit progression to an advanced cancer stage. Such metastases can either develop concurrently with an existing cancer diagnosis (termed metachronous SM) or emerge as the initial indication of an undiagnosed malignancy (referred to as synchronous SM). The present study investigates the prognostic implications of synchronous compared to metachronous SM following surgical resection.MethodsFrom 2015 to 2020, a total of 211 individuals underwent surgical intervention for SM at our neuro-oncology facility. We conducted a survival analysis starting from the date of the neurosurgical procedure, comparing those diagnosed with synchronous SM against those with metachronous SM.ResultsThe predominant primary tumor types included lung cancer (23%), prostate cancer (21%), and breast cancer (11.3%). Of the participants, 97 (46%) had synchronous SM, while 114 (54%) had metachronous SM. The median overall survival post-surgery for those with synchronous SM was 13.5 months (95% confidence interval (CI) 6.1–15.8) compared to 13 months (95% CI 7.7–14.2) for those with metachronous SM (p = 0.74).ConclusionsOur findings suggest that the timing of SM diagnosis (synchronous versus metachronous) does not significantly affect survival outcomes following neurosurgical treatment for SM. These results support the consideration of neurosurgical procedures regardless of the temporal pattern of SM manifestation.

Improved Prediction of Epidermal Growth Factor Receptor Status by Combined Radiomics of Primary Nonsmall-Cell Lung Cancer and Distant Metastasis.

This study aimed to investigate radiomics based on primary nonsmall-cell lung cancer (NSCLC) and distant metastases to predict epidermal growth factor receptor (EGFR) mutation status. A total of 290 patients (mean age, 58.21 ± 9.28) diagnosed with brain (BM, n = 150) or spinal bone metastasis (SM, n = 140) from primary NSCLC were enrolled as a primary cohort. An external validation cohort, consisting of 69 patients (mean age, 59.87 ± 7.23; BM, n = 36; SM, n = 33), was enrolled from another center. Thoracic computed tomography-based features were extracted from the primary tumor and peritumoral area and selected using the least absolute shrinkage and selection operator regression to build a radiomic signature (RS-primary). Contrast-enhanced magnetic resonance imaging-based features were calculated and selected from the BM and SM to build RS-BM and RS-SM, respectively. The RS-BM-Com and RS-SM-Com were developed by integrating the most important features from the primary tumor, BM, and SM. Six computed tomography-based features showed high association with EGFR mutation status: 3 from intratumoral and 3 from peritumoral areas. By combination of features from primary tumor and metastases, the developed RS-BM-Com and RS-SM-Com performed well with areas under curve in the training (RS-BM-Com vs RS-BM, 0.936 vs 0.885, P = 0.177; RS-SM-Com vs RS-SM, 0.929 vs 0.843, P = 0.003), internal validation (RS-BM-Com vs RS-BM, 0.920 vs 0.858, P = 0.492; RS-SM-Com vs RS-SM, 0.896 vs 0.859, P = 0.379), and external validation (RS-BM-Com vs RS-BM, 0.882 vs 0.805, P = 0.263; RS-SM-Com vs RS-SM, 0.865 vs 0.816, P = 0.312) cohorts. This study indicates that the accuracy of detecting EGFR mutations significantly enhanced in the presence of metastases in primary NSCLC. The established radiomic signatures from this approach may be useful as new predictors for patients with distant metastases.

A novel prognostic scoring system combining the revised Tokuhashi score and the New England spinal metastasis score for preoperative evaluation of spinal metastases.

Numerous scoring systems have been developed in order to determine the prognosis of spinal metastases. Predicting as accurately as possible the life expectancy of patients with spinal metastatic disease is very important, as it's the decisive factor in selecting the optimal treatment for the patient. The Revised Tokuhashi score (RTS) and the New England Spinal Metastasis score (NESMS) are popular scoring systems used to determine the optimal treatment modality. However, they sometimes provide conflicting results. We propose a novel prognostic scoring system, which combines the RTS and NESMS scores in order to predict with greater accuracy the prognosis. We retrospectively reviewed the data of 64 patients with spinal metastasis enrolled between 2012 and 2021 in the Department of Orthopedic Surgery-Spine, Hôpital Maisonneuve-Rosemont, Montréal, Que. The new score per patient was calculated as a combination of the RTS of each patient and the patient's corresponding NESMS. The new score was then compared to the actual patient survival period and divided into 3 categories: Low, Moderate and Good prognosis. We then compared the accuracy of our new score to RTS. In the Low Prognosis group, the reliability of predicting the prognosis was 51.9% in 27 patients. In the Moderate Prognosis group, the reliability of predicting the prognosis was 95.8% in 24 patients. In the Good Prognosis group, the reliability of predicting the prognosis was 100% in 13 patients. Our new score was found more accurate than RTS as the R2 parameter corresponding to the new score was significantly increased compared to the same parameter corresponding to the RTS score indicating a higher percentage of survival predictability for the new score as compared to the RTS score. This study demonstrates that a new prognostic scoring system, which would combine the RTS and the NESMS, is promising in providing an improved accuracy for predicting the actual patient survival, especially for the moderate and good prognosis patients. An appropriate prospective investigation with a larger sample size should be conducted in order to further investigate the validity of this novel scoring system and its overall predictive value.

Factors associated with non-completion of palliative radiotherapy for spinal metastasis in patients with terminal cancer: a retrospective study.

Predictors of non-completion of radiotherapy (RT) should be identified to determine the optimal RT dose. Therefore, this study aimed to explore factors associated with non-completion of palliative RT in patients with terminal cancer. In this retrospective study, patients with terminal cancer who received RT (not including single-fraction RT) for relief of pain caused by spinal metastasis were categorized into complete and incomplete groups. Baseline characteristics, hematologic test data [e.g., total lymphocyte count (TLC)], performance status, palliative performance scale (PPS) score, psoas muscle index (PMI), Charlson comorbidity index, and age-adjusted Charlson comorbidity index of the patients were compared between the two groups. The complete group comprised 58 patients (median age: 68 years; female/male: 17/41; number of irradiation fractions: ≥2 to <10, 20 patients; 10, 34 patients; and >10, 4 patients), and the incomplete group comprised 9 patients (median age: 68 years; female/male: 3/6; number of irradiation fractions: ≥2 to <10, 2 patients; 10, 7 patients; and >10, 0 patient). The proportion of patient death within 1 week or 1 month was higher in the incomplete group than in the complete group. Compared with that in the incomplete group, TLC measured 1 week before RT (pre-TLC) and PMI recorded before RT were significantly higher in the complete group (P=0.013 and P=0.012, respectively). In multivariable analyses, pre-TLC was significantly associated with the incomplete group (P=0.048). Compared with the complete group, the incomplete group included several patients whose PPS scores rapidly decreased. Pre-TLC can predict non-completion of palliative RT in patients with terminal cancer.

A critical appraisal of clinical practice guidelines on surgical treatments for spinal metastasis.

As an important treatment for spinal metastasis, surgery has strict applicable conditions. Although various organizations have formulated different guidelines on surgical treatment for spinal metastasis (SM), there are certain differences in the content, standardization and quality of the guidelines and it is necessary to make a critical appraisal of them. We aim to systematically review and appraise the current guidelines on surgical treatments of SM and summarize the related recommendations with the quality evaluation of supporting evidence, as to provide a reference for the standardization of surgical treatment plans, and help clinical front-line medical workers can make safe and effective clinical decisions faster. We searched Pubmed, Web of Science, and Embase for three major databases and online guideline databases. According to certain inclusion and exclusion criteria, the latest guidelines on the surgical treatment of SM were sorted out. AGREE II was used to evaluated the guideline's quality, and we extracted and compared the recommended treatment content of each guideline with evaluating by the evidence-grading scale. Eight guidelines from 2013 to 2019 were included. Seven guidelines are comprehensive guidelines and one related to the reconstructive surgery of SM. Five guidelines were evaluated as "recommended," and three guidelines were evaluated as "recommended with modifications." Regarding the indications of surgery with SM, four guidelines, seven guidelines, seven guidelines, three guidelines and three guidelines recommended surgical treatment for patients with SM with intractable pain, mechanical instability, metastatic epidural spinal cord compression (MESCC), recurrent spinal metastasis (RSM), and survival predication, respectively. Regarding the surgical strategies, three guidelines recommended minimally invasive therapy but had strict indications. Six guidelines and five guidelines recommend palliative surgery and with receiving radiation therapy, respectively. For the aggressive surgery, only one guideline recommended to apply to patients in good general conditions who has isolated symptomatic SM. Regarding the surgical reconstructions, one guideline didn't recommend iliac bone graft and three guidelines recommended PMMA bone cement. Most of the guidelines do not provide clear criteria for surgical application and provide more of a basic framework. The level of evidence for these surgical recommendations ranges from LOE B to D, and almost all guidelines recommend vertebroplasty and kyphoplasty, but for palliative and more aggressive surgery, which recommended to personalize specific surgical strategies with multidisciplinary collaboration.

Assessing visibility and bone changes of spinal metastases in CT scans: a comprehensive analysis across diverse cancer types.

To analyze the characteristics of spinal metastasis in CT scans across diverse cancers for effective diagnosis and treatment, using MRI as the gold standard. A retrospective study of 309 patients from four centers, who underwent concurrent CT and spinal MRI, revealing spinal metastasis, was conducted. Data on metastasis including total number, volume, visibility on CT (visible, indeterminate, or invisible), and type of bone change were collected. Through chi-square and Mann-Whitney U tests, we characterized the metastasis across diverse cancers and investigated the variation in the intra-individual ratio representing the percentage of lesions within each category for each patient. Out of 3333 spinal metastases from 309 patients, 55% were visible, 21% indeterminate, and 24% invisible. Sclerotic and lytic lesions made up 47% and 43% of the visible and indeterminate categories, respectively. Renal cell carcinoma (RCC), prostate cancer, and hepatocellular carcinoma (HCC) had the highest visibility at 86%, 73%, and 67% (p < 0.0001, p < 0.0001, and p = 0.003), while pancreatic cancer was lowest at 29% (p < 0.0001). RCC and HCC had significantly high lytic metastasis ratios (interquartile range (IQR) 0.96-1.0 and 0.31-1.0, p < 0.001 and p = 0.005). Prostate cancer exhibited a high sclerotic lesion ratio (IQR 0.52-0.97, p < 0.001). About 39% of individuals had invisible or indeterminate lesions, even with a single visible lesion on CT. The intra-individual ratio for indeterminate and invisible metastases surpassed 18%, regardless of the maximal size of the visible metastasis. This study highlights the variability in characteristics of spinal metastasis based on the primary cancer type through unique lesion-centric analysis.

Stereotactic Radiosurgery for Patients with Spinal Metastases from Thyroid Cancer: A 20-Year Experience

Primary thyroid cancer metastasizing to the spine portends poor survival and low quality of life. Current management strategies continue to evolve. This single-institution retrospective study analyzes outcomes after spinal stereotactic radiosurgery (SRS) for patients with spinal metastases from thyroid cancer. Nineteen patients (median age: 64.5 years) were treated with SRS for spinal primary thyroid metastases (40 metastases, 47 vertebral levels) between 2003-2023. Nineteen (47.5%) lesions had epidural involvement, and 20 (50%) lesions were classified as potentially unstable or unstable via the Spinal Instability Neoplastic Score. The median tumor volume per lesion was 33 cc (range: 1.5-153). The median single-fraction prescription dose was 20 Gy (range: 12-23.5). The median follow-up period was 15 months (range: 2-40). Five (12.8%) lesions locally progressed at a median of 9 months (range: 4-26) after SRS. The 1-, 2-, and 3-year local tumor control rates per lesion were 90.4%, 83.5%, and 75.9%, respectively. On univariate analysis, age at SRS > 70 years (p=0.05, HR: 6.86, 95% CI: 1.01-46.7) was significantly correlated with lower rates of local tumor control. The median overall survival was 35 months (range: 2-141). The 1-, 2-, and 3-year overall survival rates were 73.7%, 50.4%, and 43.2%, respectively. For 33 lesions initially associated with pain, patients reported pain improvement (22 lesions, 66.7%), stability (10 lesions, 30.3%), and worsening (1 lesion, 3.0%) after SRS. One patient developed dysphagia 4 months after SRS treatment. SRS can be utilized as an effective and safe primary and adjuvant treatment option for primary thyroid metastases to the spine.

Robotic Stereotactic Body Radiotherapy for Spine Metastasis Pain Relief

Spinal metastasis may occur in 40–70% of patients with cancer. Symptoms can vary from pain to spinal cord compression (SCC) and can affect their quality of life (QoL). Stereotactic body radiotherapy (SBRT) allows dose escalation of spinal tumor metastases, minimizing doses to organs at risk and improving pain control. The aim of this study is to retrospectively describe our institution’s experience with robotic SBRT (CyberKnife®, Accuray Incorporated, Sunnyvale, CA, USA) for spinal metastases, in terms of feasibility, oncological results, toxicities, and pain relief observed. In total, 25 patients with 43 lesions were assessed, most of them with dorsal metastases (48.8%). The median total dose was 27 Gy (16–35 Gy), the median number of fractions administered was 3 (1–5), and the median dose per fraction was 9 Gy. Pain was evaluated using the visual analogue scale at baseline and at the end of treatment. The statistically significant reduction in pain (p &lt; 0.01) was associated with the total dose of radiotherapy delivered (p &lt; 0.01). Only one patient developed grade 3 dermatitis. Female gender, adenocarcinoma tumors, and lack of previous surgery were associated with better response to SBRT (p &lt; 0.05). Robotic spine SBRT is feasible, well-tolerated, and improves patients’ QoL through a statistically significant reduction in pain, so it should be offered to patients at an early stage in their process.

Comprehensive Management of Spine Metastasis in Cancer Patients: From Identification to Rehabilitation

Comprehensive Management of Spine Metastasis in Cancer Patients: From Identification to Rehabilitation

Stereotactic body radiotherapy for treatment of spinal metastasis: A systematic review of the literature.

Advances in local and systemic therapies continue to improve overall survival for patients with cancer, increasing the incidence of spine metastases. Up to 15% of patients with solid tumors develop spinal metastases. Spinal metastases can be particularly devastating for quality of life given the potential pain, neurological deficits from spinal cord compression or cauda equina syndrome, spinal instability, and pathological fractures that may result. Stereotactic body radiotherapy (SBRT) with or without adding less invasive surgical techniques for stabilization or separation has gained favor. SBRT uses smaller, more precise treatment volumes, allowing for higher doses per fracture, thus increasing ablative abilities. We conducted a systematic review using MEDLINE, Embase (Elsevier), and Web of Science to identify all articles investigating the effectiveness of SBRT in providing local disease control, pain control, and relief of spinal cord compression for patients with metastatic disease of the spine. The review yielded 84 articles that met inclusion criteria. The evidence indicates SBRT provides excellent local control and pain control for patients with spine metastesis, and this remains true for patients with spinal cord compression managed with surgical separation followed by postoperative spine SBRT. While not all patients are appropriate candidates for SBRT, carefully considering appropriate frameworks that consider the patient's overall prognosis can guide a multidisciplinary team toward the patients who will benefit the most from this treatment modality.

ROLE OF MAGNETIC RESONANCE IMAGING IN THE EVALUATION OF SPINAL CORD LESIONS IN A TERTIARY CARE HOSPITAL, HYDERABAD

Background: Using other imaging modalities, subtle bone marrow, soft tissue, and spinal cord abnormalities, which may not be apparent, can be readily detected on magnetic resonance imaging (MRI). Prompt and accurate diagnosis, expeditious management, and avoidance of unnecessary procedures are achieved by early detection. Aim: The aim is to study the role of MRI in diagnosing spinal cord lesions. Methods: This study was conducted during the period from November 2018 to November 2020 and it is a prospective descriptive study of 50 patients who were referred to the Department of Radiodiagnosis Osmania General Hospital and MNJ Institute of Oncology and Regional Cancer Centre, Hyderabad, Telangana. Results: In the present study of 50 cases, different spinal cord lesions were found. The most common spinal cord lesions were neoplastic (38%) followed by spinal cord trauma (28%), and congenital lesions (16%). The most common spinal lesions were found in the 20–29 age group (40%), with more male predilection of 72% in comparison to 28% female in the present study. Out of 19 neoplastic lesions, the most common type of intramedullary spinal cord tumor (IMSC) is ependymoma (31.5%). The second most common IMSC tumor is astrocytoma 15.7% of all neoplastic lesions in the present study and the most common tumor among children. The most common location of the lesion is the thoracic cord. Hemangioblastomas constitute 10.5% of all spinal cord tumors in the present study. Meningiomas which are intradural extramedullary lesions constituted 10.5%. Neurofibroma constituted 5.2% which are intradural extramedullary with extradural component noted in NF1. Spinal cord metastasis constituted 26.3%. Intradural intramedullary lesions constituted 48% followed by extradural lesions 40% followed by intradural extramedullary lesions 12%. Conclusion: MRI by virtue of non-invasiveness, lack of radiation hazard, and the ability to demonstrate structural changes is an investigation of choice for spinal cord pathologies. The ability to image the cord directly rather than indirectly as in myelography, the absence of bone artifacts as in computed tomography, and the multiplanar capabilities indicate that MRI is the procedure of choice in the examination of the spinal cord.

Clinical and oncologic outcomes of posterior only total en bloc spondylectomy for spinal metastasis involving third lumbar vertebra: A case series.

A posterior-only total en bloc spondylectomy (TES) of the L3 level was deemed a highly intricate surgical procedure, necessitating the preservation of the L3 nerve root to prevent neurological deterioration. Despite bilateral preservation efforts of the L3 nerve roots, neurological deterioration proved unavoidable. This study aims to present the clinical, neurologic, and oncologic outcomes of spinal metastasis patients who underwent a posterior-only approach TES, encompassing the L3 vertebra. All patients with L3-involved spinal metastasis undergoing posterior TES between January 2018 and January 2022 were investigated. The primary outcomes considered were the local recurrence rate and manual muscle testing of the lumbar myotome. Secondary outcomes included Frankel neurological status, operative time, blood loss, perioperative and postoperative complications, and Eastern Cooperative Oncology Group score. Five patients with TES involving L3 (three females) met the inclusion criteria. All patients had solitary metastases (three in the lungs, 2 in the breasts). Postoperatively, all patients experienced weakness of the hip flexors, but they were able to ambulate independently 12 months after surgery. One patient exhibited adjacent segment (L2) disease progression and underwent corpectomy 18 months after TES. No local recurrences at the surgical site were detected on magnetic resonance imaging at the 1-year follow-up. Posterior-only TES for L3-involved vertebrae yielded excellent results in the local control of metastatic disease. Despite hip flexor weakness, all patients were able to regain independent ambulation after 12 months. TES can offer favorable clinical and oncological outcomes in patients with solitary spinal metastases.

Evaluation of epidemiological and pathological features of symptomatic spinal metastases in Romania - what could we learn from a retrospective study?

Metastases are the most common tumors of the spine. As an important increase in the annual incidence of spinal metastases (SMs) has been observed in the last decade, the aim of this study was to describe the epidemiology and histopathological types of SMs surgically treated in the Neurosurgery Clinics of a Regional Hospital in North-Eastern Romania over a period of five years, in order to define a certain tumor profile that would benefit from an early screening. We retrospectively evaluated 115 adult patients, searching for demographic data (gender and age of the patients), primary tumor characteristics (location and histological type), topography of the SMs, and the time interval between the diagnosis of the primary tumor and the surgery for the SMs. The patients were elderly (average age: 58.96 years), with a male predominance (67.82%). Main location of SMs was in thoracic region (44.34%), with multiple vertebral metastases in 30.43% of patients. Only 33.04% of the patients had a known cancer at the time of admission. Primary tumor was located mainly in lung (47.82%), gastrointestinal tract (15.65%), breast (11.30%), prostate (10.43%) and kidney (9.56%). SMs from lung cancer (LC) mostly expressed squamous cell carcinoma (19.13%), probably due to patients' smoking habits, and those from the digestive system mostly exhibited a moderately/poor colorectal adenocarcinoma (8.69%). Our data suggest the need for close surveillance of patients diagnosed with LC and colorectal cancer because these malignancies most frequently develop SMs. Smoking prevention actions and screening programs for the detection and removal of precancerous colorectal lesions must be developed and expanded.

Clinical Characteristics, Surgical Outcomes, and Risk Factors for Emergency Surgery in Patients With Spinal Metastases: A Prospective Cohort Study.

To elucidate the patient characteristics and outcomes of emergency surgery for spinal metastases and identify risk factors for emergency surgery. We prospectively analyzed 216 patients with spinal metastases who underwent palliative surgery from 2015 to 2020. The Eastern Cooperative Oncology Group performance status, Barthel index, EuroQol-5 dimension (EQ5D), and neurological function were assessed at surgery and at 1, 3, and 6 months postoperatively. Multivariate analysis was performed to identify risk factors for emergency surgery. In total, 146 patients underwent nonemergency surgery and 70 patients underwent emergency surgery within 48 hours of diagnosis of a surgical indication. After propensity score matching, we compared 61 patients each who underwent nonemergency and emergency surgery. Regardless of matching, the median performance status and the mean Barthel index and EQ5D score showed a tendency toward worse outcomes in the emergency than nonemergency group both preoperatively and 1 month postoperatively, although the surgery greatly improved these values in both groups. The median survival time tended to be shorter in the emergency than nonemergency group. The multivariate analysis showed that lesions located at T3-10 (p = 0.002; odds ratio [OR], 2.92; 95% confidence interval [CI], 1.48-5.75) and Frankel grades A-C (p < 0.001; OR, 4.91; 95% CI, 2.45-9.86) were independent risk factors for emergency surgery. Among patients with spinal metastases, preoperative and postoperative subjective health values and postoperative survival are poorer in emergency than nonemergency surgery. Close attention to patients with T3-10 metastases is required to avoid poor outcomes after emergency surgery.