Treatment Of Vertebral Metastases Research Articles

Navigating the Indeterminate Zone: Surgeons' Decision-Making Factors in Treating Vertebral Metastases with Spinal Instability Scores of 7–12

BackgroundThe Spinal Instability Neoplastic Score (SINS) classification system, is a validated and the most widely accepted instrument for defining instability in vertebral metastasis (VM), in which lesions scoring between 7 – 12 are defined as indeterminate and the treatment is controversial. This study aimed to determine which variables more frequently are considered by spine surgeons for choosing between the conservative and the surgical treatment of VMs among patients with an indeterminate SINS. Material and MethodsA single-round online survey was conducted in ten spine surgeons with expertise in the management of VMs from our AO Spine Region. In this survey, each surgeon independently reviewed demographic and cancer-related variables of 36 real-life cases of patients with vertebral metastases scored between 7 – 12 in the SINS. Bivariate and multivariate analyses were performed to identify significant SINS and non-SINS variables influencing the decision-making on surgical treatment. ResultsThe most commonly variables considered important, were the SINS element ‘mechanical pain’, rated important for 44.4% of the cases, ‘lesion type’ for 36.1%, ‘degree of vertebral collapse’ and the non-SINS factor ‘tumor histology’ rated for 13.9% of cases. By far the factor most commonly rated unimportant was ‘posterior element compromise’ (in 72.2% of cases). ConclusionsSurgeons relied on mechanical pain and type of metastatic lesion for treatment choices. Vertebral collapse, spinal malalignment, and mobility were less influential. Spinal mobility was a predictor of surgical versus non-surgical treatment. The only variables not identified either by surgeons themselves or as a predictor of surgery selection was the presence/degree of posterolateral/posterior element involvement.

Translated article] The role of minimally invasive spine surgery in the treatment of vertebral metastasis: A narrative review

BackgroundSpinal metastases are a very common problem which dramatically affects the quality of life of cancer patients. The objective of this review is to address the issue of how minimally invasive surgery can play an important role in treating this pathology. MethodsA literature review was performed, searching in the Google Scholar, PubMed, Scopus and Cochrane databases. Relevant and quality papers published within the last 10 years were included in the review. ResultsAfter screening the 2184 initially identified registers, a total of 24 articles were included for review. ConclusionMinimally invasive spine surgery is specially convenient for fragile cancer patients with spinal metastases, because of its reduced comorbidity compared to conventional open surgery. Technological advances in surgery, such as navigation and robotics, improve accuracy and safety in this technique.

Translated article] Tumor ablation and vertebral augmentation in the treatment of vertebral metastases: A multicenter study

IntroductionTreatment of metastatic vertebral fractures without neural compression is performed with percutaneous cementation techniques. The increase in intratumoral pressure by these techniques can send tumor cells into the bloodstream. To prevent this dissemination and improve pain treatment, ablation techniques have been introduced that would allow the creation of a cavity in the tumor prior to cementation or directly necrosing the metastasis when its size is small. MaterialWe present the experience with ablation of two hospitals and two different ablation techniques. The first group used radiofrequency ablation (A) in 14 patients (26 vertebrae), 4 of whom underwent vertebral arthrodesis. The second group used microwave ablation (B) in 93 patients (129 lesions) without associated vertebral instrumentation. ResultsIn group A pain improvement in VAS was 7.7–2.6 at 6 weeks. There were no complications derived from the ablation. In most cases cementation was associated. In the group B pain improvement in VAS went from 6.8 to 1.7 at 6 weeks. Cementation was associated in all cases. There were no complications derived from the ablation. ConclusionThe association of ablation techniques with vertebral cementation is a safe technique that significantly improves the patient's pain and can help control the disease.

Translated article] The role of minimally invasive spine surgery in the treatment of vertebral metastasis (Part 1): A clinical review

Spinal metastases represent a significant burden on the quality of life in patients affected by active oncological disease due to the high incidence of pain syndromes, spinal deformity, and neurological impairment. Surgery plays a decisive role in improving quality of life by controlling pain, restoring neurological function and maintaining spinal stability, as well as contributing to the response to medical therapy. Minimally invasive surgery (MIS) is a treatment option in certain patients with high surgical risk since it has a low rate of complications, intraoperative bleeding, hospital stay, and offers similar results to open surgery.In this review, we present the role of MIS in this pathology and some cases treated in our hospital.

Development and validation of a radiofrequency ablation treatment planning system for vertebral metastases.

Bone-targeted radiofrequency ablation (RFA) is widely used in the treatment of vertebral metastases. While radiation therapy utilizes established treatment planning systems (TPS) based on multimodal imaging to optimize treatment volumes, current RFA of vertebral metastases has been limited to qualitative image-based assessment of tumour location to direct probe selection and access. This study aimed to design, develop and evaluate a computational patient-specific RFA TPS for vertebral metastases. A TPS was developed on the open-source 3D slicer platform, including procedural setup, dose calculation (based on finite element modelling), and analysis/visualization modules. Usability testing was carried out by 7 clinicians involved in the treatment of vertebral metastases on retrospective clinical imaging data using a simplified dose calculation engine. In vivo evaluation was performed in a preclinical porcine model (n = 6 vertebrae). Dose analysis was successfully performed, with generation and display of thermal dose volumes, thermal damage, dose volume histograms and isodose contours. Usability testing showed an overall positive response to the TPS as beneficial to safe and effective RFA. The in vivo porcine study showed good agreement between the manually segmented thermally damaged volumes vs. the damage volumes identified from the TPS (Dice Similarity Coefficient = 0.71 ± 0.03, Hausdorff distance = 1.2 ± 0.1mm). A TPS specifically dedicated to RFA in the bony spine could help account for tissue heterogeneities in both thermal and electrical properties. A TPS would enable visualization of damage volumes in 2D and 3D, assisting clinicians in decisions about potential safety and effectiveness prior to performing RFA in the metastatic spine.

Single- vs. Two-Fraction Spine Stereotactic Radiosurgery for the Treatment of Vertebral Metastases

Single- vs. Two-Fraction Spine Stereotactic Radiosurgery for the Treatment of Vertebral Metastases

Multilevel percutaneous kyphoplasty in painful osteolytic vertebral metastases: a study of the efficacy and safety.

Purpose: The spine is the most common skeletal site for metastatic tumors. In the treatment of vertebral metastases, the absolutely safe number of levels that can be treated via percutaneous kyphoplasty (PKP) during one procedure remains controversial. Thus, the present study aimed to evaluate the safety and efficacy of multilevel (>3) PKP for painful osteolytic vertebral metastases.Patients and methods: We retrospectively analyzed the data from 176 patients who received PKP for painful osteolytic spinal metastases. Group A (n=104) received PKP at a maximum of three vertebral levels per procedure, while group B (n=72) received PKP at more than three levels during one operation. Surgical efficacy was assessed via a comparison of the VAS, Oswestry Disability Index (ODI), and general health (GH) and mental health (MH) scores of the Short Form-36 Health Survey before and after PKP. The complications were observed to evaluate the safety.Results: Both groups had significantly improved VAS, ODI, GH and MH scores after PKP (P<0.05). One week after surgery, group A had significantly less pain (VAS 3.41±0.1) than group B (VAS 3.74±0.13) (P<0.05). At 3 and 6 months postoperatively, the GH score was more significantly improved in group A than group B (P<0.05). There were no significant differences between the two groups in the ODI, MH score, and complications (P>0.05).Conclusion: Multilevel PKP is safe and results in effective pain relief, and improvement of spinal mobility and GH in patients with osteolytic vertebral metastases. However, patients who undergo PKP at more than three levels have slightly worse short-term pain relief (less than 1 week postoperatively) and improvement of GH in the long-term (more than 3 months postoperatively) compared with patients who undergo PKP at less than three levels.

Abstract No. 491 Simultaneous bipedicular radiofrequency ablation for local tumor control of vertebral metastases

To evaluate the safety and effectiveness of simultaneous bipedicular radiofrequency ablation (RFA) for local tumor control of vertebral metastases. Thirty-five spinal lesions in 29 patients were treated, of which 31/35 (89%) and 19/35 (54%) involved the posterior vertebral body and pedicle, respectively. Sixty percent of the lesions involved 75% or more of the vertebral body. Lesions were treated with two articulating, navigational bipolar RFA probes (STAR, Merit) simultaneously to allow more confluent overlapping ablation zone to encompass as much vertebral body volume as possible while minimizing risk of thermal injury and impedance by using variable wattage (3, 5, 7.5, or 10 watts). Mean total ablation times per probe were 18.3 minutes (range, 9.9–29.3) with overlapping ablations zones performed anteriorly, posteriorly, and within the pedicle. Postablation cementoplasty was performed in all cases via the same introducer cannula. Complications were assessed based on the Society of Interventional Radiology classification. Postprocedure local tumor control was defined as the absence of residual enhancement on contrast-enhanced MRI, radiotracer activity on PET, or stability of osteolysis on CT. All lesions were successfully ablated without any complications or thermal injury. Of the 28 lesions with postprocedure imaging, local tumor control was observed in 96% (27/28) of cases at a mean follow-up of 12.7 weeks (range, 1–48). Retraction of epidural tumor was seen in 3 cases. Simultaneous bipedicular RFA is safe and effective in the treatment of vertebral metastases, including those involving the posterior vertebral body and pedicle. This novel technique supports the stereotactic spine radiation surgery paradigm to treat the entire vertebral body and pedicles (i.e. clinical target volume) to account for microscopic disease and marginal failures for better local tumor control rates and more durable pain relief.

Chirurgie des métastases osseuses du rachis

The multiplicity of clinical presentations and the recent therapeutic developments observed in various domains explain the lack of consensus for the management of vertebral metastases. In order to propose the most appropriate therapeutic solution for each individual situation, the treatment of vertebral metastases can now be conceived only within a multidisciplinary team uniting oncologists, radiotherapists, interventional radiologists, rheumatologists and spine surgeons. As with other disciplines, vertebral surgery has benefited from numerous technical innovations to offer our patients safer therapeutic solutions while limiting operative iatrogenism. In this article, we will attempt to describe the contribution of different surgical techniques within the existing therapeutic arsenal. We will also show that spinal surgery can in no way be conceived as an exclusive competitive treatment. This treatment must be combined with other therapeutic solutions such as interventional radiology, radiotherapy or onco-rheumatology, as part of a rational and individualized care project.

The treatment of vertebral metastases from renal cell carcinoma: a retrospective study.

Renal cell carcinoma (RCC) is among the ten most common cancers in both men and women. It comprises 2-3% of all malignancies. The most common site for metastasis from RCC is the lung (50% of patients), followed by the skeleton (20% to 50% of patients). We retrospectively reviewed our consecutive series of 63 patients surgically treated for spinal metastases from RCC. The surgical treatment for spinal metastases varied in each patient. Factors influencing the choice of surgery included age, disease status, symptoms, morbidity of the patient, the location, the number of repetitive lesions and the existence of extra-osseous metastases. For 42 patients (66.66%) the treatment included radiation two weeks after the surgical procedure. A total of 68 surgical procedures were performed in 63 patients. For all patients we collected data about type of RCC, locations of metastasis, type of spine metastasis, type of surgery and complications. In this way we had an exahustive vision of the natural history of this kind of patients. Spine metastatic RCC has a poor prognosis. The favorable prognostic factor is solitary spinal metastasis without involvement of visceral organs where the gold standard treatment is corpectomy en bloc. The negative prognostic factors are the presence of one or more pathological fractures and neurological deficits. Bisphosphonate as zoledronic acid reduce significantly skeletal morbidity and significantly prolong time to bone lesion progression in patients with spine metastases from renal cell carcinoma.

High-Dose Hypofractionated Radiation Therapy for Noncompressive Vertebral Metastases in Combination With Zoledronate: A Phase 1 Study

Hypofractionated stereotactic radiation therapy (HSRT) for vertebral metastases gives good results in terms of local control but increases the risk of fracture in the treated volume. Preclinical and clinical studies have shown that zoledronate not only reduces the risk of fracture and stimulates osteoclastic remodeling but also increases the immune response and radiosensitivity. This study aimed to evaluate the tolerability and effectiveness of zoledronate in association with radiation therapy. We conducted a multicenter phase 1 study that combined HSRT (3×9Gy) and zoledronate in patients with vertebral metastasis (NCT01219790). The principal objective was the absence of spinal cord adverse reactions at 1year. The secondary objectives were acute tolerability, the presentation of a bone event, local tumor control, pain control, progression-free survival, and overall survival. Thirty patients (25 male, 5 female), median age 66years, who were followed up for a median period of 19.2months, received treatment for 49 vertebral metastases. A grade 3 acute mucosal adverse event occurred in 1 patient during the treatment and in 2 more at 1month. No late neurologic adverse events were reported at 1year. The mean pain scores diminished significantly at 1month (1.35; P=.0125) and 3months (0.77; P<.0001) compared with pain scores at study entry (2.49). Vertebral collapse in the irradiated zone occurred in 1 (2%) treated vertebra. Control of local disease was achieved in 94% of irradiated patients (3 local recurrences). The combination of zoledronate and HSRT in the treatment of vertebral metastasis is well tolerated and seems to reduce the rate of vertebral collapse, effectively relieve pain, and achieve good local tumor control with no late neurologic adverse effects.

Interventional pain techniques in the treatment of cancer pain

Three quarters of patients with advanced cancer experience moderate to severe pain, often at multiple sites. Despite advancements in the understanding of appropriate multimodal analgesia 5–14% of patients do not have adequate pain control. This has led to the suggestion that the WHO ladder should be modified with a fourth step, that of interventional procedures and techniques. This article focuses on the commonly used interventional techniques, including nerve blockade and nerve destruction techniques and will cover epidural injections, radiofrequency (RF) ablation, cryo-lesioning and trigger point injections. Vertebroplasty and kyphoplasty techniques used in the treatment of vertebral metastases associated pain is also discussed. In addition this article will consider some of the unique challenges that physicians face when treating this group of patients. Although there is limited evidence looking into the efficacy of interventional procedures in this group of patients they are nevertheless an important and accepted part of the armory against complex cancer pain and should be considered in refractory cases.

Compliance with evidence-based guidelines for radiation of vertebral metastases.

36 Background: Evidence based guidelines pertaining to the management of bony metastases have been published. However, up to 30% of oncology treatments deviate from evidence based standards and widespread variations in clinical practice continue to exist. To explore patterns of care in the treatment of vertebral metastases in a group of working age, insured patients, we assessed treatment plans submitted for preauthorization through eviti Connect. Methods: Eviti Connect is a web-based application that enables oncology providers to obtain automated precertification for patients. The platform evaluates treatment plans for consistency with EBM and compliance with payer policies and plan language. All requests for radiation treatment submitted during a two year period from 6/1/11-5/31/13 were reviewed. Peer to peer discussions were conducted in cases that deviated from EBM. Results: A total of 229 cases for the treatment of vertebral metastases were submitted. 46/229 plans (19.8%) did not meet EBM standards. Some cases displayed more than one deviation. Reasons for non-compliance included atypical treatment schedules (8.69%), SRS/SBRT (36.9%), IMRT (32.6%), and IGRT (58.7%). In 26/46 cases (56.5%) the treating physician provided a medical rationale for the deviation. In 9 cases the physician altered the plan to be compliant; in 5 cases the physician did not agree to a change. The most common dose fractionation schedules were 30 Gy/10 fractions (48.9%) and 37.5 Gy/15 fractions (20.5%). 17 cases were treated using 20 Gy/5 fractions and only 2 cases were treated using 8 Gy X 1. Conclusions: Radiation of vertebral metastases was prescribed in accordance with EBM in the majority of cases. The main reasons for deviation were patient-specific issues that justified the medical necessity of the variance. Case review and peer to peer discussion contributed to understanding the rationale for treatment deviation from guidelines and allowed providers to bring plans into compliance with EBM. Overall only 5% of plans were non-evidence based or lacked a medical justification for deviation. Consistent with patterns of care across the US, within this group of patients, single fraction and hypofractionated radiation regimens were underutilized.

Interobserver agreement for the spine instability neoplastic score varies according to the experience of the evaluator

OBJECTIVES:To evaluate the interobserver agreement for the Neoplastic Spine Instability Score (SINS) among spine surgeons with or without experience in vertebral metastasis treatment and physicians in other specialties.METHODS:Case descriptions were produced based on the medical records of 40 patients with vertebral metastases. The descriptions were then published online. Physicians were invited to evaluate the descriptions by answering questions according to the Neoplastic Spine Instability Score (SINS). The agreement among physicians was calculated using the kappa coefficient.RESULTS:Seventeen physicians agreed to participate: three highly experienced spine surgeons, seven less-experienced spine surgeons, three surgeons of other specialties, and four general practitioners (n = 17). The agreement for the final SINS score among all participants was fair, and it varied according to the SINS component. The agreement was substantial for the spine location only. The agreement was higher among experienced surgeons. The agreement was nearly perfect for spinal location among the spine surgeons who were highly experienced in vertebral metastases.CONCLUSIONS:This study demonstrates that the experience of the evaluator has an impact on SINS scale classification. The interobserver agreement was only fair among physicians who were not spine surgeons and among spine surgeons who were not experienced in the treatment of vertebral metastases, which may limit the use of the SINS scale for the screening of unstable lesions by less-experienced evaluators.

Robotic image-guided radiosurgery for the treatment of neoplastic vertebral pain

Metastatic spinal lesions are a common event in cancer patients. Spinal metastases usually involve the vertebral bodies and are characterized by severe pain. Surgical treatment, as a consequence of its high invasivity, is rarely offered to patients with metastatic disease and expected limited life span. Spinal radiosurgery provides high rates of pain and local growth control in association with limited risk of neurological complications. The use of radiosurgery to treat spinal lesions has been strongly facilitated by the development of image-guided robotic radiosurgery, a technique able to deliver stereotactic irradiation to intra- and extracranial targets. Despite the exponential increase of treatments delivered to the spine using this novel approach and the growing number of papers reporting the outcomes of spine radiosurgery in terms of local growth control and analgesia following treatment of patients with metastatic and benign lesions of the spine, the awareness of the general medical public to the use of this technique remains limited. This paper aims to review the role of radiosurgery in the treatment of vertebral metastases and benign tumors and its efficacy in terms of pain and local growth control.

Diagnóstico y tratamiento de las metástasis vertebrales con compresión medular

Diagnóstico y tratamiento de las metástasis vertebrales con compresión medular