Vertebral Body Metastases Research Articles

A novel technique of intracavitary 125Iodine brachytherapy for vertebral body metastases

A novel technique of intracavitary 125Iodine brachytherapy for vertebral body metastases

Spinal cord compression and vertebral body metastasis diagnosed in correlation with TC-99m H/MDP scan

Spinal cord compression and vertebral body metastasis diagnosed in correlation with TC-99m H/MDP scan

Combined ovarian ablation and aromatase inhibition as first-line therapy for hormone receptor-positive metastatic breast cancer in premenopausal women: report of three cases

Aromatase inhibitors have become well established for the treatment of postmenopausal women with hormone receptor-positive metastatic breast cancer and for adjuvant hormonal therapy for primary breast cancer. Benefit of aromatase inhibition has not yet been extended to premenopausal women. Ovarian ablation by oophorectomy, ovarian radiation or hormonal suppression is the initial recommended treatment for hormone receptor-positive metastatic breast cancer in premenopausal women. The addition of tamoxifen improves the benefit of ovarian ablation/ovarian suppression. Addition of aromatase inhibitors to luteinizing hormone-releasing hormone analogs has been reported to significantly decrease circulating estrogens and produce tumor responses in only a very small number of patients over the last 15 years. We treated three premenopausal patients with hormone receptor-positive metastatic breast cancer with combined oophorectomy or ovarian irradiation and anastrozole. One patient remained free of progression for 4 years, while the other two remained free of progression for more than 5 and 3 years, respectively. We also note that monthly zoledronic acid for 4 years produced sclerosis of vertebral body metastasis. We conclude that combined ovarian ablation and aromatase inhibition is a feasible treatment modality that deserves more attention and further investigation for hormone receptor-positive metastatic breast cancer in premenopausal women.

Aufklärungsgespräch mit einer Patientin über den Wechsel des Behandlungsansatzes vom kurativen zum palliativen Setting

Palliative care is fortunately gaining importance in the treatment of endstage oncological patients. Patient information regarding therapeutic strategies, especially when treatments are suggested to alleviate symptoms and are not curing the disease can be the most challenging part. Our case of a 49 year old female presenting with a colorectal adenocarcinoma and vertebral body metastasis required spinal stabilization surgery to prevent paralysis. However, she did not consent to the necessary treatment, completely refusing to recognize the seriousness of her disease. In spite of many attempts to enlighten her, the disease was allowed to progress, and it was only when thrombosis caused massive edema of the right leg that the patient finally started to ask about prognosis and potential treatment. An interdisciplinary approach to provide medical and psychosocial help could be established. This case shows the typical problems of a physician-patient relationship in an oncologic clinic and emphasizes the importance of integrating medical with psychosocial care.

Surgical resection improves outcome in metastatic epidural spinal cord compression

In today's Lancet, Roy Patchell and colleagues 1 Patchell RA Tibbs PA Regine WF et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet. 2005; DOI:10.1016/S0140-6736(05)66954-1 PubMed Google Scholar present the long awaited outcome of a randomised trial of decompressive surgical resection in patients with metastatic epidural spinal cord compression (MESCC), which will have a major effect on the therapeutic approach to these patients. MESCC is a great threat for all cancer patients with vertebral body metastases, which can lead to paraplegia. The current standard of care consists of a high level of suspicion toward cancer patients with back pain, a low threshold for performing MRI, and immediate radiotherapy in cases of spinal cord compression. Once paraplegia develops the outlook for the patient is grim. Not only does paraplegia severely affect quality of life, but the functional response to radiotherapy mainly depends on the ambulatory status of the patient at the start of treatment: most ambulant patients will remain ambulant, but non-ambulant patients rarely recover to an ambulant status and have a very limited survival. 2 Helweg-Larsen S Sorensen PS Kreiner S Prognostic factors in metastatic spinal cord compression: a prospective study using multivariate analysis of variables influencing survival and gait function in 153 patients. Int J Radiat Oncol Biol Phys. 2000; 46: 1163-1169 Summary Full Text Full Text PDF PubMed Scopus (216) Google Scholar Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trialDirect decompressive surgery plus postoperative radiotherapy is superior to treatment with radiotherapy alone for patients with spinal cord compression caused by metastatic cancer. Full-Text PDF Open Access

Renal cell carcinoma vertebral body metastasis extending into the azygos venous system causing superior vena cava obstruction

We describe a case of superior vena cava (SVC) obstruction caused by extension of tumour thrombus from a vertebral body metastasis through the azygos system to the SVC. The primary tumour was a renal cell carcinoma.

Subarachnoid—pleural fistula after resection of thoracic tumors

Little has been written about the appropriate diagnosis, investigation, and management of subarachnoid-pleural fistula (SPF). The authors report a series of patients with SPF that developed after resection of spinal tumor and discuss the diagnosis and treatment of this entity. Between 1993 and 2002, nine patients with SPF observed after spinal surgery at the M. D. Anderson Cancer Center were prospectively followed. In all patients the tumors were located in the thoracic region, and the most common entity was vertebral body metastasis (six cases), with renal cell carcinoma being the most common form of the disease (three cases). All but one patient underwent surgery via a transthoracic approach; in only one patient an intradural approach was performed. The most common presentation was overt cerebrospinal fluid (CSF) leakage, manifesting as chest tube drainage (four cases) or as leakage through the wound (one case). A definitive diagnosis of SPF was established in four patients, with evidence of extraspinal leakage on an 111In-radionuclide CSF study. Although all patients initially underwent a trial of lumbar CSF drainage, all but one required open repair, including creation of intercostal muscle (three cases) and omental (one case) flaps. After spinal surgery in which the thorax is entered, a diagnosis of SPF should be considered in any patient with abnormal chest tube output, persistent pleural effusion, or clinical evidence of intracranial hypotension. The diagnosis should be confirmed by performing a radionuclide-labeled CSF study. Definitive open repair is required in most cases and preferentially consists of a vascularized tissue graft, which is most easily obtained from an intercostal muscle flap.

Metastatic spine tumors.

Cancer is the second leading cause of death in the United States, and vertebral body metastases often occur in systemic malignancy. Metastatic spinal tumors may present with pain or neurologic deficit, or may be detected during screening examinations in patients with known malignancy. Management of spinal metastases remains controversial. The role of surgery, especially decompressive laminectomy without stabilization, has been questioned. Recent series attest to the beneficial role of surgery, emphasizing anterior and combined decompression and stabilization procedures. We review the relevant literature on metastatic spinal tumors, assessing imaging strategies, adjuvant treatment, patient selection, and results and complications. Operative decompression and stabilization is an important tool in the management of spinal metastatic disease. Patient selection and appropriate use of anterior and/or posterior decompression and stabilization are necessary to optimize surgical results.

Metastatic Meningioma to the Second Cervical Vertebral Body

A rare case of C2 vertebral body metastasis from a parasagittal meningioma is reported. The metastatic lesion was found 13 years after resection of the primary lesion. The primary and the metastatic lesions had a similar and benign histological appearance. Remote metastasis of a meningioma can occur even with a benign histological finding after a variable disease-free period.

Supportive care in oncology

Pain management, nutritional support, and psychosocial support are fundamental services that enhance patients' ability to cope with their cancer and its therapy. The common goal of symptom prevention mandates that each of these supportive services be provided to all patients throughout their cancer experience. Comprehensive cancer pain management begins with identifying the origin of all of the patient's pains and treating each one specifically. Pain prevention can be achieved through around-the-clock opioid administration with as-needed supplements for breakthrough pain and dose titration. Common narcotic side effects such as constipation and nausea also must be prevented. Successful opioid analgesia requires that patient and family concerns regarding addiction and tolerance be dispelled at the outset. Cancer pain prevention can be further optimized with the use of appropriate coanalgesics in response to the pathophysiology of the patient's pains. Cognitive and behavioral therapies may also be useful adjuncts to reduce both pain and suffering. Procedure-oriented pain control should be considered when systemic pharmacologic therapy does not provide adequate pain relief or is associated with intolerable side effects. The only absolute contraindications for pain-relieving procedures are untreatable coagulopathy and a decrease in mental status not related to medical pain management. Useful neurodestructive techniques include radiofrequency lesionining, cryoanalgesia, and chemical neurolysis with agents such as phenol, alcohol, and hypertonic saline. The most beneficial pain-relieving procedures and percutaneous cordotomy, spinal narcotics, celiac and hypogastric plexus ablation, spinal neurolysis, and epidural injection of steroids and hypertonic saline. Procedure selection depends on the cause of the pain and the patient's prognosis. Common indications for pain-relieving procedures include unilateral pain below the shoulder, upper abdominal visceral pains, pelvic visceral pain, perineal pain, vertebral body metastasis, discogenic pain, and spinal stenosis. As results of well-conducted scientific trials begin to appear in the literature, the indications for these procedures will be better understood, resulting in their more appropriate use. Principles of nutritional support in patients with cancer include an awareness of the problem of malnutrition and its impact on performance status, quallity of life, prognosis, and treatment; identification of those patients at risk; prophylactic versus therapeutic intervention; and analysis and management of the specific impediment(s) to adequate nutrient intake and absorption. The primary goals for nutritional support in cancer patients are prevention of weight loss and maintenance of adequate protein status. Appreciation of practical issues of nutritional support will enable the practicing physician to achieve these goals using primarily oral nutrition options. General indications for parenteral nutrition include significant malnutrition, a nonfunctional gastrointestinal tract, and active oncologic treatment options. Prevention of psychosocial distress is also crucial to effective supportive care in oncology. The quality of the physician-patient relationship is crucial to its success and a primary component of patient mastery of the cancer experience. Factors that affect this relationship include physician practice structure, communication techniques, family-oriented care, ancillary support services, and physician well-being. Differences between individual and group counseling modialities must be appreciated to optimize their benefit. Improvements in survival mandate that physicians meet their responsibility to help patients cope most effectively with their cancer. Effective pain management, nutritional support, and psychosocial support complement effective cancer therapy and must be integrated into each patient's comprehensive cancer care. Such total care will enhance survival and reduce the burden of cancer for patients and their caregivers.

Paraplégie après rachianesthésie

A case of paraplegia occurring after a spinal anaesthetic is reported. The 79-year-old man was admitted for a fractured neck of femur. Twenty years previously, he had had pharyngeal surgery and a tracheostomy. He had also undergone a prostatectomy for prostate cancer, and had been on oestrogen therapy for two years. He complained of dyspnoea at rest and his chest film showed diffuse pulmonary opacities. In order to avoid possible intubation and respiratory complications, spinal anaesthesia was performed without any problems in the L4 space. After the surgery, the patient recovered all his motor and sensory functions in the lower limbs. On the second postoperative day, he suffered from a motor paralysis of the right leg, which spread to the left leg on the fourth day. NMR imaging showed several vertebral metastases, together with anterior and lateral epidural invasion responsible for cord compression. Treatment with tetracosactide was begun, but the patient died six weeks later in his home, not having recovered any neurological function at all in his lower limbs. In fact, it was only after the procedure that the anaesthetist was informed that, at the time the prostate cancer had been diagnosed, vertebral body metastases, of which the patient had not been informed, were already present. The part played by the spinal anaesthetic in the occurrence of the paraplegia is not clear. It is reminded that such a technique should be used with extreme care in patients having a neoplasm with a very often high incidence of vertebral metastases.

Supportive care in oncology

Pain management, nutritional support, and psychosocial support are fundamental services that enhance patients' ability to cope with their cancer and its therapy. The common goal of symptom prevention mandates that each of these supportive services be provided to all patients throughout their cancer experience. Comprehensive cancer pain management begins with identifying the origin of all of the patient's pains and treating each one specifically. Pain prevention can be achieved through around-the-clock opioid administration with as-needed supplements for breakthrough pain and dose titration. Common narcotic side effects such as constipation and nausea also must be prevented. Successful opioid analgesia requires that patient and family concerns regarding addiction and tolerance be dispelled at the outset. Cancer pain prevention can be further optimized with the use of appropriate coanalgesics in response to the pathophysiology of the patient's pains. Cognitive and behavioral therapies may also be useful adjuncts to reduce both pain and suffering. Procedure-oriented pain control should be considered when systemic pharmacologic therapy does not provide adequate pain relief or is associated with intolerable side effects. The only absolute contraindications for pain-relieving procedures are untreatable coagulopathy and a decrease in mental status not related to medical pain management. Useful neurodestructive techniques include radiofrequency lesioning, cryoanalgesia, and chemical neurolysis with agents such as phenol, alcohol, and hypertonic saline. The most benefecial pain-relieving procedures and percutaneous cordotomy, spinal narcotics, celiac and hypogastric plexus ablation, spinal neurolysis, and epidural injection of steroids and hypertonic saline. Procedure selection depends on the cause of the pain and the patients prognosis. Common indications for pain-relieving procedures include unilateral below the shoulder, upper abdominal visceral pains, pelvic visceral pain, perineal pain, vertebral body metastasis, discogenic pain, and spinal stenosis. As results of well-conducted scientific trials begin to appear in the literature, the indications for these procedures will be better understood, resulting in their more appropriate use. Principles of nutritional support in patients with cancer include an awareness of the problem of malnutrition and its impact on performance status, quality of life, prognosis, and treatment; identification of those patients at risk; prophylactic versus therapeutic intervention; and analysis and management of the specific impediment(s) to adequate nutrient intake and absorption. The primary goals for nutritional support in cancer patients are prevention of weight loss and maintenance of adequate protein status. Appreciation of practical issues of nutritional support will enable the practicing physician to achieve these goals using primarily oral nutrition options. General indications for parenteral nutrition include significant malnutrition, a nonfunctional gastrointestinal tract, and active oncologic treatment options. Prevention of psychosocial distress is also crucial to effective supportive care in oncology. The quality of the physician-patient relationship is crucial to its success and a primary component of patient mastery of the cancer experience. Factors that affect this relationship include physician practice structure, communication techniques, family-oriented care, ancillary support services, and physician well-being. Differences between individual and group counseling modalities must be appreciated to optimize their benefit. Improvements in survival mandate that physicians meet their responsibility to help patients cope most effectively with their cancer. Effective pain management, nutritional support, and psychosocial support complement effective cancer therapy and must be integrated into each patient's comprehensive cancer care. Such total care will enhance survival and reduce the burden of cancer for patients and their caregivers.

Malignant Schwannoma (Neurofibrosarcoma) Metastatic to Spine

We report a case of a patient with pulmonary metastases as well as T8 and T9 vertebral body metastases causing compression fracture and epidural spinal cord compression

Renal metastases shown by 99mTc-methylene diphosphonate scintigram which failed to detect vertebral metastases

A patient with breast metastases is presented showing increased nodular renal uptake of tracer on bone scintigraphy that also demonstrated rib metastases and a large metastasis in the pelvis. However, vertebral body metastases were not shown when clearly demonstrated on CT with even partial compression on a thoracic spine film. Most of the renal lesions were hypoechoic on sonography, showed hypoattenuation areas on plain CT and after contrast enhancement but no calcification could be demonstrated. This case once again illustrates the value of scrutinizing the soft tissues on scintigraphy but also the possibility of showing some metastases on CT not visible on scintigraphy.