Vertebral Metastases Research Articles

Spinal Metastases in Non-Seminomatous Germ Cell Testicular Tumors: Prognosis and Integrated Therapeutic Approaches—A Systematic Review with an Institutional Case Illustration

(1) Background: Testicular cancer, although accounting for only 0.5% to 1% of all solid male cancers, is the most common malignancy in males aged 15 to 35 years. Non-seminomatous germ cell tumors (NSGCT) represent nearly half of all testicular germ cell tumors and are associated with a more aggressive clinical course. Spinal metastases, while rare, pose significant challenges due to their potential to cause spinal cord compression, neurological deficits, and severe pain. This systematic review aims to evaluate prognosis and treatment approaches for spinal metastases in NSGCT, with a focus on multidisciplinary care and treatment outcomes. (2) Methods: A systematic review was conducted following PRISMA guidelines. PubMed, Scopus, and Embase were searched on 18 September 2024, using the Boolean search strategy [(Nonseminomatous germ cell tumor (NSGCT) AND (spinal OR vertebral metastases)]. Case reports, case series, and cohort studies providing detailed patient data were included. Data on patient demographics, tumor histology, metastatic site, treatments, and outcomes were extracted for analysis. (3) Results: A total of 164 cases of NSGCT with spinal metastases were analyzed, with patients aged 23 to 40 years (median: 31.5 years). The lumbar spine was involved in all cases, and spinal cord compression occurred in 59.8% of patients, often causing severe neurological symptoms such as cauda equina syndrome. Chemotherapy, primarily cisplatin-based, was administered in all cases, while surgical interventions, including laminectomy and vertebrectomy, were performed in cases of spinal compression and instability. Complete remission occurred in only 2.4% of patients. Progressive improvement was observed in 56.7% of cases, while 20.1% of patients died. Outcomes varied, highlighting the importance of individualized, multidisciplinary care to manage both systemic and localized disease. (4) Conclusions: Spinal metastases in NSGCT represent a complex clinical scenario, requiring a combination of chemotherapy, surgery, and in some cases, radiotherapy. Chemotherapy remains essential, but surgery is critical for addressing spinal compression and instability. A multidisciplinary approach is vital for optimizing outcomes, as prognosis is variable, with some patients achieving improvement while others face progressive disease or death. Further research is needed to refine the role of radiotherapy and improve long-term treatment strategies for this rare complication.

Frequency of Positive Findings on MRI of The Patients Diagnosed with Vertebral Metastases on Bone Scintigraphy

Objective: The present study is conducted with the aim to compare the bone scan and MRI findings for detecting spinal metastasis in our local population. Study design and duration: This cross sectional study was conducted at Radiology Department of Pakistan Institute of medical Sciences, Islamabad from May 2019-May 2020. Material and Methods: Total 30patients with confirmed diagnosis of cancer who were suspected for spinal metastasis on Tc-99m bone scan and sent for radiologic workup for confirm diagnosis of s pine lesions were enrolled. MRI was performed on 1.5-tesla system using standard protocol. Spine was divided into four regions: cervical, thoracic, lumber and sacral regions. Region-wise bone metastasis were analyzed and compared for bone scan and MRI. Interpretations were considered concordant if both reports showed positive for metastatic lesions, while discordant if readings differ. Results: 63.3% of the study population were female. Mean age of the enrolled patients was 59.3±14.9 years. All the lesions of cervical region were concordant. Most of the discordance for MRI was noted for lumbar region, where 7 patients were reported as negative who were positive on bone scan. In case of bone scintigraphy, 2 patients were discordant for thoracic region who were positive on MRI. Conclusion: Very low discordance rate exists among MRI and bone scan. MRI is an effective imaging tool for detection of spinal metastasis with added benefits of no radiation dose to the patient and wider availability as compare to the bone scintigraphy.

Safety and aesthetic outcomes of double purse-string suture nipple reconstruction in early breast cancer patients undergoing nipple resection and endoscopic skin-sparing mastectomy with breast reconstruction.

The current surgical methods for managing incisions after nipple excision in breast reconstruction patients are limited. However, double purse-string suture (DPS) shows promise in the treatment of nipple excision. This study aimed to investigate the safety and aesthetic outcomes of DPS nipple reconstruction in early breast cancer patients who underwent endoscopic skin-sparing mastectomy (E-SSM) and breast reconstruction. We retrospectively analyzed the clinical data of 87 early breast cancer patients with nipple excision who underwent E-SSM with breast reconstruction. According to the suture methods of nipple incision, all patients were divided into the spindle suture (SS) group, single purse-string suture (SPS) group, and DPS group, with SS and SPS groups combined as the traditional suture (TS) group. Then, we compared the groups' differences in aesthetic outcomes, surgical safety, and oncological safety. A total of 87 patients with 88 breasts were enrolled in this study (SS n=17, SPS n=21, DPS n=50). Patients in the DPS group had significantly better nipple reconstruction satisfaction, Harris scale and any complications incidence than the TS group (all p <0.05). For nipple reconstruction satisfaction and any complication, the adjusted OR (95%CI) of the DPS group were 6.314(1.095-36.415) (p=0.039) and 0.124(0.018-0.863) (p=0.035) compared with the SS group. One patient in the SS group had vertebral metastases, and no recurrence, metastasis, or death has been observed in the other two groups during the follow-up period. DPS is an effective and safe nipple reconstruction procedure for patients undergoing E-SSM with breast reconstruction, delivering excellent aesthetic outcomes.

AB075. When would minimally invasive spinal surgery not be preferable for metastatic spine disease?-a narrative review.

Metastatic spine tumour surgery (MSTS) is an important treatment modality of metastatic spinal disease (MSD). Open spine surgery (OSS) was previously the gold standard of treatment. However, advancements in MSTS in recent years has resulted in a current paradigm shift towards today's gold standard of minimally invasive spinal surgery (MISS) and early adjuvant RT in treating MSD patients. Nonetheless, there are still certain situations whereby MISS is not desirable or even suitable. There has also yet to be any literature describing the considerations for not using MISS in MSD in today's clinical context. We aim to bridge the gap where OSS should be considered with caution and highlight situations where MISS is preferable using the available literature and personal experience. This narrative review was conducted using PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), The Cochrane Library and Scopus databases through August 31, 2023. Inclusion criteria for the review were studies with discussion on the type of surgery in MSTS. A total of 52 studies were included in this review. We discussed various advantages and situations appropriate for MISS for MSD in today's clinical context. Nonetheless, there are still various unique circumstances in which MISS may be less suitable. MISS is less feasible in patients of paediatric profile, having short stature or having had previous surgery at the level of operation. Occipitocervical and cervicothoracic location of vertebrae metastasis also makes MISS less feasible due to access and imaging difficulty. MISS for tumours which are hypersclerotic and hypervascular can also result in more difficulty for cannulation of MISS probes as well as control of bleeding respectively, and hence will be less encouraged in the above settings. Our review will be the first to discuss circumstances in which MISS is less applicable, despite the advantages it may confer over traditional OSS. MSTS should be individualized to the patient, depending on the experience of the surgeon. OSS is still a time-tested approach that holds weight in MSTS and should be readily utilized depending on the clinical situation.

[Translated article] Diagnostic imaging in patients with vertebral compression fractures

Vertebral compression fractures by osteoporosis (OVF) is usually a diagnostic problem and coincides on the age group of metastatic vertebral compression fractures (MVF). Although radiography is the first diagnostic technique, generally is not accurate for depicting demineralization and soft tissue lesions. Magnetic resonance (MRI) is the diagnostic choice. The most relevant signs are intravertebral fluid collection or fluid signal, other vertebral deformities without oedema and older age. Among the most relevant findings for diagnosis MVF are soft tissue mass and pedicle intensity signal asymmetries. However, reproducibility of these findings in clinical practice is moderate.

Back Pain as Presenting Main Symptom in Incidental Finding of Lung Nodule EGFR Mutation: A Case Report

Lung cancer can spread to the bones, and when it affects the spine, it can be initially misdiagnosed as a common musculoskeletal cause of back pain. We present the case of a formerly healthy 59-year-old male smoker with no pulmonary symptoms who presented with a two-month history of back pain before developing spinal cord compression syndrome. It was later discovered that he suffered from vertebra metastasis T7 level with stenosis canalis spinal due to metastasis adenocarcinoma solitary pulmonary nodule. The patient also presented a positive epidermal growth factor receptor (EGFR) mutation. Laminectomy and posterior stabilization with tyrosine kinase inhibitor therapy are performed on the patient. It underscores the significance of conducting lung cancer screenings and the criticality of vigilantly observing for warning signs of back pain, such as progressive worsening back pain symptoms despite treatment.

The Truly Intermediate Subgroup Within the SINS “Potentially Unstable” Category: The Matryoshka Doll Phenomenon

A significant dilemma exists for the surgical plan of spinal metastases with a spinal instability neoplastic score (SINS) of 7-12. Our aim is to trim down this range of "potential instability" and find a virtual cut-off value for instrumentation. We performed a retrospective study on 60 patients who underwent surgical intervention for vertebral metastasis. They were segregated into 'instrumented' and "noninstrumented" groups. The primary endpoint of the study was to see whether surgical stabilization was done. Although univariate analysis showed the overall SINS score, involvement of posterior elements, and mechanical pain to be the factors that significantly affected our decision making in favor of stabilization, only the SINS score was found to be statistically significant on multivariate analysis. On plotting the proportion of patients undergoing stabilization at each SINS score we found the curves to crossover between SINS 8 and 9, ran almost parallel to each other at values 9 and 10 and then seemed to diverge from each other significantly at values above 10. Taking SINS 9 as the cut-off value above which instrumentation is advised, the receiver operating characteristic curve had a sensitivity of 67.57% (95% confidence interval 50.21% to 81.99%) and specificity of 73.91% (95% confidence interval 51.59% to 89.77%). The area under the curve was 0.79 (0.67-0.91). SINS 9-10 seems to be the actual ambiguous subset in the wider subgroup of the 'potentially unstable' category SINS 7-12, like a 'Matryoshka doll'. A SINS value of 9 can be seen as a cut-off value for instrumentation.

Antitumor effect of vertebroplasty in vertebral metastasis based on quantitative 18F-FDG-PET/CT analysis

Antitumor effect of vertebroplasty in vertebral metastasis based on quantitative 18F-FDG-PET/CT analysis

Development of a natural language processing algorithm for the detection of spinal metastasis based on magnetic resonance imaging reports

BackgroundMetastasis to the spinal column is a common complication of malignancy, potentially causing pain and neurologic injury. An automated system to identify and refer patients with spinal metastases can help overcome barriers to timely treatment. We describe the training, optimization and validation of a natural language processing algorithm to identify the presence of vertebral metastasis and metastatic epidural cord compression (MECC) from radiology reports of spinal MRIs. MethodsReports from patients with spine MRI studies performed between January 1, 2008 and April 14, 2019 were reviewed by a team of radiologists to assess for the presence of cancer and generate a labeled dataset for model training. Using regular expression, impression sections were extracted from the reports and converted to all lower-case letters with all nonalphabetic characters removed. The reports were then tokenized and vectorized using the doc2vec algorithm. These were then used to train a neural network to predict the likelihood of spinal tumor or MECC. For each report, the model provided a number from 0 to 1 corresponding to its impression. We then obtained 111 MRI reports from outside the test set, 92 manually labeled negative and 19 with MECC to test the model's performance. ResultsAbout 37,579 radiology reports were reviewed. About 36,676 were labeled negative, and 903 with MECC. We chose a cutoff of 0.02 as a positive result to optimize for a low false negative rate. At this threshold we found a 100% sensitivity rate with a low false positive rate of 2.2%. ConclusionsThe NLP model described predicts the presence of spinal tumor and MECC in spine MRI reports with high accuracy. We plan to implement the algorithm into our EMR to allow for faster referral of these patients to appropriate specialists, allowing for reduced morbidity and increased survival.

The Efficacy of a Multidisciplinary Approach and Diagnostic-Therapeutic Algorithm for Vertebral Metastases with Spinal Cord Compression.

Background and Objectives: Metastatic spinal cord compression represents a substantial risk to patients, given its potential for spinal cord and/or nerve root compression, which can result in severe morbidity. This study aims to evaluate the effectiveness of a diagnostic-therapeutic algorithm developed at our hospital to mitigate the devastating consequences of spinal cord compression in patients with vertebral metastases. Materials and Methods: The algorithm, implemented in our practice in January 2022, is based on collective clinical experience and involves collaboration between emergency room physicians, oncologists, spine surgeons, neuroradiologists, radiation oncologists, and oncologists. To minimize potential confounding effects from the COVID-19 pandemic, data from the years 2019 and 2021 (pre-protocol) were collected and compared with data from the years 2022 and 2023 (post-protocol), excluding the year 2020. Results: From January 2022 to December 2023, 488 oncological patients were assessed, with 45 presenting with urgency due to suspected spinal cord compression. Out of these, 44 patients underwent surgical procedures, with 25 performed in emergency settings and 19 cases in elective settings. Comparatively, in 2019 and 2021, 419 oncological patients were evaluated, with 28 presenting with urgency for suspected spinal cord compression. Of these, 17 underwent surgical procedures, with 10 performed in emergency scenarios and 7 in elective scenarios. Comparing the pre-protocol period (years 2019 and 2021) to the post-protocol period (years 2022 and 2023), intrahospital consultations (commonly patients neurologically compromised) for spine metastasis decreased (105 vs. 82), while outpatient consultations increased remarkably (59 vs. 124). Discussion: Accurate interpretation of symptoms within the context of metastatic involvement is crucial for patients with a history of malignancy, whether presenting in the emergency room or oncology department. Even in the absence of a cancer history, careful interpretation of pain characteristics and clinical signs is crucial for diagnosing vertebral metastasis with incipient or current spinal cord compression. Early surgical or radiation intervention is emphasized as it provides the best chance to prevent deficits or improve neurological status. Preliminary findings suggest a notable increase in both the number of patients diagnosed with suspected spinal cord compression and the proportion undergoing surgical intervention following the implementation of the multidisciplinary protocol. The reduced number of intrahospital consultations (commonly patients neurologically compromised) and the increased number of visits of outpatients with vertebral metastases indicate a heightened awareness of the issue, leading to earlier identification and intervention before neurological worsening necessitating hospitalization. Conclusions: A comprehensive treatment planning approach is essential, and our multidisciplinary algorithm is a valuable tool for optimizing patient outcomes. The protocol shows potential in improving timely management of spinal cord compression in oncological patients. Further analysis of the factors driving these changes is warranted. Limitations: This study has limitations, including potential biases from the retrospective nature of data collection and the exclusion of 2020 data due to COVID-19 impact. To enhance the robustness of our results, long-term studies are required. Moreover, the single-center study design may limit the validity of the findings. Further multicenter studies would be beneficial for validating our results and exploring underlying factors in detail.

Rethinking Strategies for Multi-Metastatic Patients: A Comprehensive Retrospective Analysis on Open Posterior Fusion Versus Percutaneous Osteosynthesis in the Treatment of Vertebral Metastases.

Background: Managing vertebral metastases (VM) is still challenging in oncology, necessitating the use of effective surgical strategies to preserve patient quality of life (QoL). Traditional open posterior fusion (OPF) and percutaneous osteosynthesis (PO) are well-documented approaches, but their comparative efficacy remains debated. Methods: This retrospective study compared short-term outcomes (6-12 months) between OPF and PO in 78 cancer patients with spinal metastases. This comprehensive evaluation included functional, clinical, and radiographic parameters. Statistical analysis utilized PRISM software (version 10), with significance set at p < 0.05. Results: PO demonstrated advantages over OPF, including shorter surgical durations, reduced blood loss, and hospital stay, along with lower perioperative complication rates. Patient quality of life and functional outcomes favored PO, particularly at the 6-month mark. The mortality rates at one year were significantly lower in the PO group. Conclusions: Minimally invasive techniques offer promising benefits in VM management, optimizing patient outcomes and QoL. Despite limitations, this study advocates for the adoption of minimally invasive approaches to enhance the care of multi-metastatic patients with symptomatic VM.

Early Vertebral Metastases in Non-Muscle-Invasive Bladder Cancer: A Case Report

Most urinary tract tumors are bladder cancers, whereas NMIBCs are the most common. In NMIBC, distant metastases are extremely rare, and imaging for staging is rarely requested without warning signs, nor recommended. Nonetheless, non-muscle invasive bladder cancers can develop distant metastases without regional progression. We present a case of NMIBC with vertebral metastasis in a young man with no risk factors for bladder tumors who responded well to systemic therapy. We also discuss possible explanations for this rare occurrence.

Percutaneous Vertebral Augmentation and Thermal Ablation in Patients with Spinal Metastases.

Vertebral augmentation and thermal ablation offer radiologists a robust minimally invasive option for treatment of patients with spinal metastases. Such interventions are commonly combined and have proved safe and effective in the management of selected patients with vertebral metastases with durable treatment effects. Special attention to procedure techniques including choice of vertebral augmentation technique, choice of ablation modality, and thermal protection is essential for improved patient outcomes. This article provides a review of the most recent advances in vertebral augmentation and thermal ablation for the treatment of spinal metastases.

An Unusual Presentation of Squamous Cell Carcinoma in a Never Smoker: A Case Report

Lung Cancer is one of the most common types of cancer found among smokers. However, approximately 10% of lung cancer patients are non-smokers. Non-smokers are frequently seen developing Adenocarcinoma, a type of non-small cell carcinoma with a female predominance. The incidence of Squamous cell carcinoma among non-smokers is very low. Moreover, studies have shown that tetra site metastasis in the case of Squamous cell carcinoma of the lung is almost as rare as 0.6% [1]. The authors report here in this article a case report of a rare and aggressive presentation of Squamous cell carcinoma in a non-smoker. This is a case of a 50-year-old male patient who is a non-smoker, presented with complaints of exertional dyspnoea and cough with expectoration for 3 months which had aggravated since 15 days, associated with hoarseness of voice and diffuse headache since 15 days. There was a history of significant weight loss and loss of appetite for 3 months. CECT thorax revealed a heterogeneously enhancing mass lesion in the anterior segment of the left upper lobe encasing the left pulmonary artery with evidence of liver, adrenal and vertebral metastasis. During the hospital stay, the patient developed complete ptosis of the right eye. MRI brain was done which showed features suggestive of metastasis involving bilateral cerebral and cerebellar hemispheres. USG guided lung biopsy was done and was suggestive of moderately differentiated Squamous cell carcinoma. The patient was planned to be further worked up for IHC markers and PET CT scan to determine the further line of treatment however, unfortunately, the patient succumbed to the disease within 1 week of histopathological diagnosis.

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.

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.

Hidden blood loss and its influencing factors after cement augmentation for vertebral metastasis

IntroductionFew studies have focused on the risk factors for hidden blood loss (HBL) during cement augmentation surgery for pathologic vertebral compression fraction (PVCFs). MethodFrom January 2014 to December 2020, the clinical data of 169 PVCF patients (283 levels) who underwent cement augmentation were retrospectively analysed. HBL was calculated according to the linear Gross formula using the patient's average Hct during the perioperative course and PBV. Multivariate linear regression analysis was performed to evaluate the independent factors associated with HBL. ResultsThe mean HBL was 448.2 ± 267.2 ml, corresponding to 10.8% ± 6.2% of the patient blood volume (PBV). There were significant differences between pre- and postoperative haematocrit (Hct) (P < 0.001) and Hb (P < 0.001), and 132 patients developed anaemia postoperatively, while 79 patients had anaemia preoperatively (P < 0.001). Multivariate linear regression revealed that bone lesion quality (p = 0.028), number of PVCFs (p = 0.002), amount of bone cement (p = 0.027), bone cement leakage (p = 0.001), and percentage of vertebral height loss (VHL) (p = 0.011) were independent risk factors for HBL. ConclusionIn conclusion, patients with lytic vertebral destruction, larger amounts of bone cement, greater amounts of bone cement leakage, more PVCF(s), and greater percentages of VHL may be more prone to HBL.

Lung adenocarcinoma with brain metastasis detected dual fusion of LOC399815-ALK and ALK-EML4 in combined treatment of Alectinib and CyberKnife: A case report.

The anaplastic lymphoma kinase (ALK) gene fusion occurs in approximately 3% to 7% of nonsmall cell lung cancer (NSCLC), in which occurs approximately 23% to 31% of brain metastasis patients in poor prognosis. ALK tyrosine kinase inhibitors have shown efficacy in treating ALK-positive (ALK+) NSCLC. More than 90 distinct subtypes of ALK fusions have been identified through sequencing technique and would lead to significant differences in clinical efficacy, it is necessary to guide clinical treatment effectively by gene detection. A 56-year-old nonsmoking female admitted to hospital due to cough, expectoration, and chest pain. Chest computed tomography revealed a space-occupying lesion in the upper left lobe (5.0 cm × 2.4 cm × 2.9 cm), multiple enlarged lymph nodes in mediastinum 3A and 5 (largest size 1.5 cm × 1.4 cm), and evidence of thoracic vertebral metastasis, brain magnetic resonance imaging also showed brain metastasis. Lung adenocarcinoma with brain metastasis. The patient initially received conventional first-line chemotherapy, which led to a deteriorated condition. Blood-base liquid biopsy by next-generation sequencing resulted in double ALK fusions, in which with a neo-partner of lncRNA (LOC399815-ALK). Following subsequent treatment with Alectinib and stereotactic radiotherapy (CyberKnife) was subsequently employed to manage the brain metastatic lesions, resulting in a substantial decreased in both the number and size of tumor lesions. The patient's response to therapy efficacy resulted in a substantial decreased in both the number and size of tumor lesions that assessed comprehensively evaluated through computed tomography imaging and ctDNA sequencing. Patient's condition has been under control for over 29 months. Liquid biopsy may reveal the rare fusion forms of ALK, precisely guiding personalized treatment, and providing a reference method for longitudinal monitoring and efficacy evaluation of ALK-tyrosine kinase inhibitors in NSCLC patients.

A retrospective cohort study on the efficacy and safety of percutaneous vertebroplasty combined with bone-filling mesh container in vertebral metastases with posterior wall defect.

To evaluate the clinical safety and efficacy of percutaneous vertebroplasty (PVP) combined with bone-filling mesh containers (BFMCs) for vertebral metastases with posterior wall defect. From January 2019 to December 2021, patients with vertebral metastases and posterior wall defect who received BFMCs combined with PVP were included. The visual analog scale (VAS) scores and Oswestry disability index (ODI) scores were evaluated before and 72 hours after the operation, respectively. Post-operational X-ray and computed tomography (CT) scans were conducted to observe bone cement leakage, and complications were recorded. Follow-up CT and magnetic resonance imaging (MRI) were conducted to evaluate the condition of the operated vertebrae and the recurrence or progression of other bone metastases. A total of 43 patients with 44 operated vertebrae were included. All patients successfully completed the surgery. The average VAS score decreased from 7.35 ± 0.78 to 1.63 ± 0.93 (p < 0.05), and the ODI score decreased from 80.06 ± 8.91 to 32.5 ± 4.87 (p < 0.05). Bone cement leakage was observed in 18 operated vertebrae, which were all asymptomatic. No intraspinal leakage, post-operative spinal nerve compression, pulmonary embolism, or other serious complications were recorded. A total of 21 patients had a follow-up of more than 1 year, with no operated vertebral progression, 13 target vertebrae showed obvious sclerosis and necrosis, and no adjacent pathological fracture occurred. Of these patients, 16 had different degrees of bone metastasis of other sites other than the operated vertebrae. For spinal metastases with posterior wall defect, PVP combined with BFMCs was highly safe and can effectively relieve pain for patients. A 1-year follow-up showed a local antitumor effect.

Delineation Errors Caused by Replication and Expansion Operations in Monaco.

This study aims to investigate the errors in structure volume and shape caused by the replication, expansion, and merging operations of the Monaco system and analyze their influence on dosimetry evaluation. A retrospective collection of 30 patients undergoing radiotherapy was utilized. Cylinders with radii of 5, 10, and 30 mm were delineated in computerized tomography (CT) images from 10 patients with thoracic and abdominal issues, and the Margins function in Monaco was used to expand the margins by 0, 3, 5, and 10 mm in 2D mode. In 10 patients with vertebral metastases, the Margins function was utilized to replicate and merge targets, and the Copy Structure function was employed to replicate targets. Cross-CT replication was performed for the targets of 10 patients with nasopharyngeal carcinoma. The deviation between the processed structure volume and the ideal value was compared. The difference in the maximum dose (Dmax) before and after lens replication was evaluated in 10 patients undergoing whole-brain radiotherapy. Monaco's Margins function increased the volume of the processed structure during the copying procedure. The margin error was equivalent to expanding the structure by 0.3-0.4 mm, and a margin error of 0.3-0.4 mm was produced in each expansion instance. The volume deviation for a cylinder with a radius of 5 mm was 12.99%. The Merge function of Margins copied substructures and merged them. The Copy Structure function did not alter the structure during copying, but the volume was reduced by less than 1% after copying across CT. Dmax after lens replication was higher than that before replication, with a median difference of 31.3 cGy for the left lenses. Monaco's Margins function introduces errors in organ replication, expansion, and merging, resulting in incorrect dose assessment. Physicians should be mindful of the potential effects when utilizing them.