Vertebral Metastases Research Articles

Results of kyphoplasty in the minimally invasive treatment of vertebral metastasis

OBJECTIVE: To evaluate the clinical and radiological outcome of minimally invasive surgical treatment of vertebral metastases using the technique of kyphoplasty. METHODS: This was a prospective observational study of patients with the diagnosis of spinal metastasis who underwent minimally invasive surgical treatment by filling the vertebral body with balloon kyphoplasty technique. Clinical evaluation included patient age at surgery, diagnosis of the tumor, biopsy results, data of the surgical procedure performed, visual pain scale (VAS) and complications related to surgery. Radiological evaluation involved the study of radiographic procedures in the anteroposterior and lateral incidences, with the analysis of vertebral body kyphosis and the occurrence of extravasation of cement. RESULTS: 22 patients with spinal metastases who were treated by balloon kyphoplasty, 8 (36%) males and 14 (64%) females were studied. The average age was 56.05 years and the mean follow-up was 8.5 months. The mean preoperative VAS was 8.73, 1.73 in the initial postoperative period, and 1.92 in the late postoperative period. CONCLUSION: Kyphoplasty proved to be a safe and effective technique for symptomatic treatment of vertebral metastases.

A patient with esophageal cancer with bone metastasis who achieved pain relief with repetitive administration of strontium-89 chloride

A 75-year-old woman was diagnosed with esophageal cancer with difficulty in swallowing. She had a past history of rheumatoid arthritis, scleroderma, interstitial pneumonia, angina pectoris (with coronary artery bypass surgery) and arrhythmia (with pacemaker implantation). She refused surgery, and chemotherapy and radiotherapy were not performed because of the high risk accompanied with multiple comorbidities. She received proton therapy at another hospital and the primary lesion shrank. Bone metastasis in the thoracic vertebrae was diagnosed 10 months after diagnosis of esophageal cancer. Non-steroidal anti-inflammatory drugs and zoledronic acid were administered for back pain. Oxycodone was also administered but discontinued due to nausea. After strontium-89 ((89)Sr) chloride administration, her back pain was relieved. (89)Sr was administered five times every 3 months, and the pain did not worsen until her death due to pneumonia 2 years after diagnosis of esophageal cancer. (89)Sr was effective for pain from bone metastasis of esophageal cancer, and its repeated administration was safe.

Resonance imaging in the diagnostics of metastatic vertebral compression fractures

Metastatic vertebral compression fractures are widespreaded throughout the world, includingUkraine. The aim was to evaluate the methodological aspects and modern modalities of magnetic resonance imaging in the diagnosis of metastatic lesions of the spine. Lack of sensitivity, specificity and sometimes difficulty in the practical application of radiographic diagnosis of this disease makes problem of finding of the new methods of diagnosis, such as magnetic resonance imaging. From a critical perspective presented and evaluated pulse sequences (T1WI, T2WI, STIR, Fat/sat) and new modalities (DWI, Whole-body), which are used in the diagnosis of metastases. Introduction of these modern technologies in the diagnostic process has great scientific interest and considerable practical significance, and will also enhance the effectiveness of the treatment of these patients.

Evaluation of scoring systems and prognostic factors in patients with spinal metastases from nasopharyngeal carcinoma

Background contextThe decision for operative treatment of patients with spinal metastases is dependent on the patient's predicted survival. Tokuhashi, Tomita, Bauer, and Oswestry scores have been devised for survival prediction; however, none of these systems have been evaluated in nasopharyngeal carcinoma (NPC). PurposeTo investigate the accuracy of these scoring systems in predicting survival and to identify prognostic factors for survival of the patients with spinal metastases from NPC. Study designRetrospective analysis of the patients with spinal metastases from NPC who were treated in our institution. Patient sampleThe study included 87 patients with spinal metastases from NPC. Outcome measuresThe primary outcome measure was the survival time of these patients. The potential prognostic factors that are known to influence survival such as general condition, extraspinal bone metastases, vertebral bone metastases, visceral metastases, and neurologic assessment based on Frankel score were also studied. MethodsThe predicted survival according to the four scoring systems were calculated and labeled as “A” scores. These patients were then rescored by assigning NPC as a good prognostic tumor and labeled as “B” scores. The predicted survival of scores A and B were compared with actual survival. Potential prognostic factors of survival were investigated using univariate and multivariate Cox regression analyses. For all scoring systems, Kaplan-Meier survival estimates and log-rank tests were done; the predictive values were calculated using postestimation after Cox regression analyses. ResultsThe median overall survival for the whole cohort was 13 (range 1–120) months. In multivariate analysis, general condition (p<.01), visceral metastases (p<.01), and vertebral metastases (p<.01) showed significant association with survival. The absolute score of all scoring systems was significantly associated with actual survival, which extended to the different prognostic subgroups of each scoring systems. Log-rank test revealed significant differences in survival between the different prognostic subgroups of all scoring systems (p<.01). Predictive value of survival by modified Tokuhashi score was the highest among all four scoring systems. ConclusionsPatients with spinal metastases from NPC have relatively good survival prognosis. All four scoring systems could be used to prognosticate these patients. The modified Tokuhashi score is the best in doing so.

Pre-Emptive Value of Methylprednisolone Intravenous Infusion in Patients With Vertebral Metastases. A Double-Blind Randomized Study

ContextThe vertebral column is the most common site of bone metastases irrespective of the primary tumor. Vertebral metastases are a major cause of motor deficit of the lower extremities. The use of radiotherapy is the treatment of choice in these patients. A temporary worsening of pain shortly during the course of palliative radiotherapy is clinically a common problem. Steroid infusion has well-documented neuroprotective effects. ObjectivesOur study objective is to evaluate the effect of pre-emptive infusion of methylprednisolone on pain flare and motor function in patients with vertebral metastases. MethodsOne hundred twenty patients with vertebral metastases received short-course external beam radiotherapy as high-voltage irradiation with a 6 MeV, via linear accelerator. In addition to the short-course radiotherapy, 60 patients received pre-emptive methylprednisolone infusion (5 mg/kg) the day just before initiation of radiotherapy (Group 1 [G1]). The other 60 patients received short-course radiotherapy without pretreatment methylprednisolone infusion, and only normal saline was infused (Group 2 [G2]). The Brief Pain Inventory, incidence of pain flare during radiotherapy, and motor functions were evaluated using the Tomita scale at the time of initial assessment, at the end of external beam radiotherapy, and after two weeks. ResultsFour patients (6.6%) in G1 experienced pain flare compared with 12 patients (20%) in G2 during the two-week short-course radiotherapy. The mean values of pain scores were significantly reduced in both groups at the end of radiotherapy; the mean value of worst, average, and current pain scores in G1 remained statistically significant in comparison to pretreatment and G2 mean values two weeks later. Significant increase was noticed in patients with normal motor and ambulatory status in G1 at two and four weeks of initial assessment. ConclusionPre-emptive methylprednisolone infusion is an effective prophylactic agent in the prevention of radiation-induced pain flare and improves functional motor status after short-term radiotherapy in patients with vertebral metastases.

Intensity modulated stereotactic body radiation therapy for single or multiple vertebral metastases with spinal cord compression

PurposeThe purpose of this study was to evaluate the efficacy and toxicity of intensity modulated radiation therapy with simultaneous integrated boost (SIB-IMRT) for single or multiple vertebral metastases (VM) with spinal cord compression using tomotherapy. Methods and materialsThirty patients with 40 VM were treated with SIB-IMRT as initial radiation therapy. Either 40 Gy in 8 fractions or 48 Gy in 16 fractions was prescribed depending on the Katagiri prognostic index. The radiation doses to the spinal cord and other risk organs were reduced to tolerance levels using intensity modulation. One to 4 lesions in consecutive vertebrae were treated in 1 course of SIB-IMRT. Radiologic and physical examinations were performed at 1-3 month intervals after SIB-IMRT. The Barthel index (BI) and numerical rating scale (NRS) were used to evaluate activities of daily living (ADL) and pain status, respectively. ResultsThe median follow-up period was 8 months. The NRS significantly dropped at 1 month after SIB-IMRT (P < .0001) and the effect continued for over 2 months. No significant BI decrease was observed at 2 months after SIB-IMRT (P = .7). The 1-year local control rate was 84% (95% confidence interval, 70%-100%). No grade≥2 neurologic toxicity resulting from SIB-IMRT was observed. ConclusionsSIB-IMRT could be successfully applied to VM with spinal cord compression in up to 4 consecutive vertebrae. Good ADL preservation and pain control were achieved with acceptable toxicity.

Hereditary paraganglioma‐pheochromocytoma syndromes associated with SDHD and RET mutations

Hereditary paraganglioma-pheochromocytoma syndromes (PGL/PCC) are rare tumors arising from neuroendocrine cells. The proband, a 59-year-old white man and his 42-year-old elder son had a medical history of bilateral carotid body PGL and both presented for treatment of abdominal PGLs. His 36-year-old daughter had excision of recurrent malignant carotid body PGL and vertebral metastasis. His 33-year-old youngest son presented for excision of a unilateral carotid body PGL. All 4 members had succinate dehydrogenase subunit D (SDHD) mutations, whereas the proband and youngest son also had concurrent rearranged during transfection (RET) mutation. This is the first report of PGL/PCC with SDHD and RET mutations. The role of the RET gene as a modifier remains speculative. Additionally, the family pedigree suggests maternal inheritance of disease from the probands' paternal grandmother. Clinicians should refer PGL/PCC families for mutation analysis as well as being alert to changes in the classification of mutations.

Recovery from paraplegia with administration of erlotinib in a patient with lung adenocarcinoma.

Recovery from paraplegia with administration of erlotinib in a patient with lung adenocarcinoma.

Percutaneous Vertebroplasty in Vertebral Metastases from Breast Cancer: Interest in Terms of Pain Relief and Quality of Life

Percutaneous vertebroplasty (PV) is a therapeutic option in patients with vertebral metastases (VM). However its efficacy in pain relief, improvement in quality of life and safety in patients with VM from breast cancer has not been reported. We present a longitudinal retrospective study of 31 consecutively treated female patients with VM from breast cancer where 88 vertebrae were treated in 44 sessions of PV, in which osteolytic, osteoblastic and mixed lesions were recorded. The visual analogue pain scale (VAS) was used to evaluate pain pre-PV, at one, three, six and 12 months post-PV. The Eastern Cooperative Group (ECOG) performance status scale was used at the same time intervals to measure quality of life: 90.3% pain relief was identified with a VAS reduction from 5.7 ± 2.0 pre-PV to 2.9 ± 2.2 post-PV at one-month follow-up (p<0.001) and 0.6 ± 1.0 at 12-month follow-up (p<0.001). In our series 48.4% of patients were classified as having an ECOG grade 0 and 1 pre-PV, which increased to 80.8% at the 12-month follow-up. While 22.6% of the patients were classified at ECOG grades 3 and 4 pre-PV, this improved to 0% at 12 months follow-up. The morbidity rate for this procedure was 12.9% immediately and only 3.2% at 30 days post-PV with all complications being resolved medically or with CT-guided infiltration. PV is a safe procedure with a high efficacy in pain relief, and improvement of quality of life in patients with diverse types of VM from breast cancer.

A Rare Case of Gastric Linitis Plastica Revealed by Isolated Vertebral Metastases in a Young Woman in a Less Developed Country

Aim: We report a rare case of gastric linitis plastica revealed by vertebral metastases without another digestive dissemination. Case presentation: The Benin native woman was hospitalized in rheumatology for inflammatory back pain without another signs. Rx ray showed vertebra metastasis. In the etiologic research, gastroscopy showed an infiltrating lesion of the antral area, indicating gastric linitis which was confirmed by biopsy. Short and medium-term evolution was favourable, characterized by a complete disappearance of the pains and a good physical condition. Conclusion: Vertebral metastases can reveal digestive cancer, although human gut is not among the most bone metastatic cancers.

Vertebral Metastasis as First Sign of Thyroid Papillary Microcarcinoma

Vertebral Metastasis as First Sign of Thyroid Papillary Microcarcinoma

Paraparesis and pleural effusion in a young patient: A road less travelled

Intrapulmonary teratoma is a rare tumor of the lung, which is scarcely reported to have metastasis at presentation. Here, we report a case of a 14-year-old patient admitted with paraparesis and heaviness of the right side of the chest and was found to have compressive myelopathy along with pleural effusion. He had elevated alpha fetoprotein and beta human chorionic gonadotropin. Imaging revealed a heterogeneous, massive space lesion occupying the right hemithorax and collapse of D12 vertebra with altered marrow signal causing extradural spinal compression. Cytopathology from the tumor revealed immature teratoma cells. The patient was diagnosed as a case of intrapulmonary teratoma with vertebral metastasis. He was started on bleomycin, etoposide, cyclophosphamide chemotherapy and spinal irradiation, which was unsuccessful.

Widely Metastatic Parotid Acinic Cell Carcinoma to Bone and Liver: A Case Report, Review of Literature, and Review of Diagnostic Challenges

Distant metastasis of salivary gland neoplasms is a rare occurrence. Generally, high-grade salivary malignancies such as salivary duct carcinoma and high-grade mucoepidermoid carcinoma, as well as tumors located in the submandibular gland, show a higher likelihood of metastasizing. Acinic cell carcinoma is an uncommon salivary gland neoplasm that typically occurs in the parotid gland and is considered a low-grade malignancy. Metastasis is unusual and, if present, predominantly involves the lung and bones. However, vertebral metastasis is exceedingly rare. Here, we describe a rare case of recurrent acinic cell carcinoma of the parotid gland with widespread metastases to multiple bones, including the vertebrae, and to the liver, which was diagnosed in part by cytology. To our knowledge, this is the first report in the cytology literature to describe salivary gland acinic cell carcinoma with metastases to such distant sites and to discuss the resulting cytologic differential diagnoses.

Ginecomastia ca Semn de Prezentare Într-o Tumoră Testiculară Prezentare de Caz

Background: Orchitis tumor incidence is rare, about 2% of male malignancies. The pathology of tumoral orchitis has a maximum incidence between the ages 20-35, in children being more frequent the embryonal carcinoma and teratoma, in adult are met all types and in elderly predominates the seminoma. About 25% has endocrine secretory capacity. The incidence of gynaecomastia in adult men is reported as being 35-65%, depending on the criteria for diagnosing gynaecomastia and the age group. However, only 2% of men presenting with gynaecomastia are founded to have testicular tumours. Case Report: We present the case of a 27 years old patient, diagnosed two years ago with testicular tumor. In diagnosis, the first sign was the unilateral gynaecomastia then neoplastic transformation of the left testicle was noted. The diagnosis was confirmed by ultrasound exam and tumoral markers (β human chorionic gonadotrophin over 5000 mUI/mL; alpha-fetoprotein at 12.3 UI/mL; lactate dehydrogenase at 1840 U/L). Left orchiectomy was performed. The pathological report showed a mixed tumor with germinal cells: embryonal carcinoma, teratoma and choriocarcinoma. The patient refuse adjuvant therapy and two months postoperatively pulmonary and vertebral metastasis were revealed. He followed radiotherapy, chemotherapy and neurosurgical treatment with complete remission. Conclusion: We emphasize the importance of complete physical exam and testicular ultrasonography in any case of suspicion of testicular tumor. The multidisciplinary approach and treatment allows good results in advanced testicular tumors.

Epidural Hematoma after the Use of Subcutaneous Unfractionated Heparin and History of Epidural Tumor

The patient was a 66-year-old male with a history of renal cell carcinoma with metastasis to the L2, L3, and L4 vertebral bodies scheduled for a radical nephrectomy and adrenalectomy. Prior to surgery the patient had undergone 10 radiation treatments for the vertebral metastasis. Patient medications included colace, prednisone, ibuprofen (taken 4 days prior to procedure), sunitinib, hydrocodone, benazepril, nexium, rosuvastatin, allopurinol, and azor. Physical exam prior to surgery was normal with no focal findings. Laboratory values were within normal limits with a platelet count of 286. General anesthesia was planned with a pre-operative thoracic epidural for postoperative analgesia. The epidural was placed at the T9-T10 level without complication. Adequate pain control was present post operatively and the epidural was discontinued on post-operative day 3. At that time the patient was noted to have numbness over the bilateral lower extremities and decreased strength. Heparin 5000 units subcutaneous had been given 12 hours prior to discontinuation of the epidural. The patient was afebrile, hemoglobin was 7, white blood cell count was 9.7, and platelets were 166 at time of epidural removal. Subcutaneous heparin was restarted 6 hours after catheter removal. The anesthesia acute pain service was contacted by the primary service 25 hours after discontinuation of the epidural catheter regarding complaints of persistentbilateral lower extremity weakness and sensory loss. An magnetic resonance image (MRI) revealeda focus posterior to the spinal cord at the T10/T11 interspace likely representing a hematoma. A high intensity T2 signal within the central spinal cord at T10/T11 was also observed; likely a vascular infarct. The patient was immediately scheduled for a T9-T10 laminectomy and evacuation of the epidural hematoma. No significant abnormalities were noted in coagulation studies prior to surgery. The patient was discharged on post-operative day 20 with no neurologic deficits.An epidural hematoma is rare with an estimated occurrence of

A preliminary study of the safety and efficacy of radiofrequency ablation with percutaneous kyphoplasty for thoracolumbar vertebral metastatic tumor treatment

BackgroundThoracolumbar vertebral metastasis (TVM) affects a large number of cancer patients. However, safe and effective palliative care remains controversial. The aim of the present study was to investigate the safety and efficacy of minimally invasive image-guided radiofrequency ablation (RFA) with percutaneous kyphoplasty (PKP) for TVM treatment.Material/MethodsA retrospective study of 26 patients (mean age: 59.31±11.62 years) was conducted, including 38 vertebral metastases at T11, T12, L1, L2, L3, L4, L5, and S1 with abundant blood vessels. Patients underwent RFA with PKP (4–6 min, 95±5°C, 150 W, effective electrode area of 1.5–2.0 cm) under general anesthesia from February 2005 to January 2009. Electrodes were inserted into the lesions and pre- and post-operative visual analog scale (VAS) scores and X-rays were collected on day 3, week 1, and months 1, 3, and 6. Tumor recurrence and pain level were also evaluated. Safety assessment was conducted based on complications and adverse events. The mean follow-up time was 8.4±2.1 months.ResultsA mean of 2.69±0.93 ablation was performed per patient. The ablation procedure required a mean of 15.08±4.64 min, while the injection of bone cement required a mean of 6.73±0.83 min, for a mean total operating time of 47.77±7.13 min. Postoperative VAS scores were significantly lower on day 3, week 1, and months 1, 3, and 6 (P<0.01), without any complications or tumor recurrence.ConclusionsImage-guided RFA with PKP was safe and effective for TVM treatment when used with careful consideration of bone cement volume/viscosity, injection location, and temperature.

Value of SPECT/CT in Cervical Vertebra Metastasis Mimicking Residual Thyroid Tissue on Planar I-131 Scan

A total thyroidectomy was performed on a 62 year-old male patient with 3.5 cm cold nodule and diagnosis of differentiated thyroid carcinoma was made. He received 200 mCi of I-131 because pulmonary metastases were founded on computed tomography and his serum thyroglobulin level was high (>300 ng/ml). Post-therapy planar whole body scan showed diffuse pulmonary tracer accumulation consistent with pulmonary metastases, 3 foci of activities in the thyroid region of neck and physiological tracer uptake in the liver. Initially, it was considered that high serum thyroglobulin level was caused by pulmonary metastases and activities in the neck were due to residual thyroid tissue. But, single photon emission computed tomography/computed tomography (SPECT/CT) images demonstrated that the activity in the midline of the neck was originated in the cervical (C5-6) vertebra due to bone metastasis. Cervical vertebra metastasis in the same level with probable residual thyroid tissue in planar I-131 whole body scan can be easily overlooked. We considered that the complementary SPECT/CT for head and neck region should be used not only in the selected differentiated thyroid patients with unexpected abnormal activity but also in patients with expected residual thyroid tissue, salivary gland or mouth activity in planar I-131 whole body scan.

68Ga DOTATATE PET/CT Uptake in Spinal Lesions and MRI Correlation on a Patient With Neuroendocrine Tumor

A 62-year-old female patient with suspected insulinoma underwent 68Ga DOTA-TATE PET/CT for characterization and staging. This demonstrated a focus of uptake in the pancreas and 3 foci of uptake in the spine. An MRI of the spine performed to further characterize the lesions revealed the presence of a meningioma and degenerative changes, both of which showed 68Ga DOTA-TATE uptake. A vertebral metastasis seen on PET was occult on CT and MRI. A vertebral hemangioma had no discrete tracer uptake. Awareness of sources of error in interpreting 68Ga DOTA-TATE scans is important in order to avoid pitfalls.

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Introduction: The posterior reversible encephalopathy syndrome (PRES) is manifested by headache and altered mental status with or without visual disturbances and seizures along with unique radiological findings. We present a case of 53 year old female with renal cell cancer who developed PRES after radical nephrectomy. Although PRES has been associated with hypertension and renal disease, and while there have been few case reports of postoperative PRES, this is the first case report to our knowledge of the syndrome occurring after a nephrectomy. A 53 year old female with well controlled hypertension and diabetes mellitus initially presented with several month history of weight loss, recurrent low grade fevers, and intermittent right lower quadrant pain. Upon imaging, she was found to have right renal mass with invasion of right renal vein and possible vertebral metastases. She underwent right radical nephrectomy with regional lymph node removal. On third post operative day, the patient developed chest pain and EKG changes and was started on anticoagulation with heparin along with aspirin and plavix. Subsequently on post operative day five, she started complaining of headache, nausea, vomiting and rapidly developed altered mental status and loss of vision without any other focal neurological weakness or ataxia. Previously well controlled blood pressure started to rise, with mean arterial pressure now ranging between 100-120 mm of Hg. Brain MRI revealed new onset edema tracking along the bilateral posterior occipital lobe white matter compatible with PRES. Also seen were right subarachnoid hemorrhage and intra-parechymal petechial hemorrhage. She received fresh frozen plasma and platelet transfusions along with strict blood pressure control with intravenous anti hypertensives. Patient had rapid recovery with resolution of altered sensorium over the next 24 hours and improvement in her visual symptoms in 48-72 hours. Patient was subsequently discharged home. We report a unique case of development of PRES syndrome occurring after nephrectomy. Our case highlights importance of early recognition of the syndrome and strict blood pressure control in such settings.

A modified posterolateral transpedicular approach to thoracolumbar corpectomy with nerve preservation and bilateral cage reconstruction

This retrospective study investigated the early results of a single-stage posterolateral transpedicular corpectomy and fusion in the thoracolumbar spine. A modified technique with nerve preservation and bilateral expandable cage implantation is described. Four patients with vertebral metastasis and one patient with vertebral osteomyelitis were included in this series. Two patients underwent two level corpectomies, whereas three patients underwent single level corpectomy. The mean follow-up was 3.3months. No perioperative complication was encountered. Improvement in neurological status was observed in patients with preoperative neurological deficits. Vertebral height and sagittal and coronal deformity were corrected using the current technique. Bilateral cage implantation offers an additional advantage of asymmetrical reconstruction of the ventral column in cases of hemicorpectomy. Single-stage posterolateral transpedicular corpectomy and fusion is a useful approach to treat ventral thoracolumbar pathologies.