Professional Documents
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Contents
Abstract
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4311
4312
4313
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Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4314
PET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4315
Treatment of Spinal Metastases and Indications for
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4318
Steroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4318
Chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4318
Radiation Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4318
Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4318
Indications and Contra-Indications . . . . . . . . . . . . . . . . 4319
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Vertebroplasty and Kyphoplasty . . . . . . . . . . . . . . . . . . .
Decompression and Instrumentation . . . . . . . . . . . . . . .
En Bloc Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4322
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4322
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4322
E. Caceres Palou
Department Hospital Vall dHebron, Autonomous
University of Barcelona, Barcelona, Spain
e-mail: ecaceres@vhebron.net
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E. Caceres Palou
4310
General Introduction
Cancer is the leading cause of death in western
world having supplanted heart disease in those
under age 85 since 1999 [1]. Recent data suggest
a progressively improving trend in survival.
Since 1993, the death rate from all cancers combined has decreased by 1.5 % per year among
men, and by 0.8 % among women. Mortality
rates continue to decrease for the three most
common sites in men (lung, colorectal, and prostate) and in women for breast and colorectal
cancer [24].
Metastatic disease to the spine is by far the
most common clinical problem confronting
spine oncologists. Some autopsy data suggest
that metastases to the spine are present in more
than 70 % of the patients with the most common
cancers (breast, lung, and prostate), these data,
comes from original article by Jaffe [5] but
could be exaggerated. Other autopsy studies
have been performed to evaluate the rate of
spinal metastasis SM. Spines from 832
deceased patients with diagnosis of malignant
neoplasm were studied grossly, microscopically, and radiographically by Wong et al. [6].
Overall metastases were disclosed in 36 % of
patients dying of neoplastic disease. Around
16 % were occult and not visible on plains
radiographies. The actual clinical incidence of
symptomatic epidural metastases causing spinal
cord and cauda equina compression is perhaps
much lower (around 5 %) [7].
Technological advances during the last two
decades have greatly expanded the possibilities
for treatment in oncology; this progress has
resulted in newer tools for diagnosis, treatment,
and follow-up.
The treatment of metastatic spine disease has
evolved significantly with the introduction of
advanced interventional, surgical and radiation
techniques. Successful treatment of SM
accomplishes effective pain palliation, maintenance or recovery of neurological function and
ambulation, local durable pain control, spinal
stability, and improved quality of life.
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Table 1 Tokuhasi score. Tokuhasi [12] proposed in 1990
a system to assess the prognosis of metastatic spine
tumours using six parameters and in 2005 revised his
system, increasing the role of the primary site of cancer
Characteristic
General condition (performance status)
Poor (PS 1040 %)
Moderate (PS 5070 %)
Good (PS 90100 %)
No. of extra spinal bone metastases foci
3
12
0
No. of metastases in the vertebral body
3
2
1
Metastases to the major internal organs
Unremovable
Removable
No metastases
Primary site of the cancer
Lung, osteosarcoma, stomach, bladder,
esophagus, pancreas
Liver, gallbladder, unidentified
Others
Kidney, uterus
Rectum
Thyroid, breast, prostate, carcinoid tumour
Palsy
Complete (Frankel A, B)
Incomplete (Frankel C, D)
None (Frankel E)
Score
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
3
4
5
0
1
2
E. Caceres Palou
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Table 2 Tomita score. Tomita [13] proposed in 2001 a three prognostic factor score for SM (Table 3)
Prognostic
score
Scoring system
Treatment
goal
Surgical
strategy
Long-term
local control
Wide or
Marginal
excision
Middle-term
local control
Marginal or
intralesional
excision
Short-term
Palliation
Palliative
surgery
Terminal
care
Supportive
care
Prognostic factors
2
Point
Primary
tumor
VIsceral
mets. *
Bone
mets.**
Solitary
or
isolated
Moderate
treatable
Multible
growth
Slow
growth
[Breast,thyroid, etc]
rapid
growth
[Kidney,uterus etc]
untreatable
[Lung,stomach, etc]
Angiogenesis
8
9
10
Table 3 Harrington Spinal Metastases categories in relation with neurological status the SM could be classified in
five categories following Harrintong [14] classification
score. Harrington classification based on structural defect
and neurological deficit
Class
I
II
II
IV
Neulogical
status
Not
significant
Not
significant
Major
(sensory or
motor)
Not
significant
Major
Structural changes
No vertebral collapse
Vertebral involvement
without collapse or instability
(lytic or blastic lesion)
No significant bone
destruction or instability
Mechanical pain from
vertebral
collapse or Instability
Retropulsion of hard
discovertebral
elements or Kyphotic
deformity
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Bone Resorption
The invasion of tumour cells at the site of skeletal metastases is very different from the
E. Caceres Palou
4314
Fig. 3 Bone resorption. The destruction of the mineralized portion of the bone is a passive process that requires
a low pH and the destruction of the portion of bone
collagen is an active process that requires the action of
enzymes collagenases. Osteoclasts destroy cells
Diagnosis
destruction that occurs in tumour cells of soft
tissue is the direct activity of the cells themselves, resorption of bone metastases occurs
with the activation of osteoclasts. Osteoclasts
destroy cells as fraction of mineralized bone
like (Fig. 3).
Eighty-five percent of metastatic spinal
lesions are located in the vertebral body, being
intramedullary. Other locations are epidural,
paravertebral and foraminal. In patients with
spinal metastasis, pathological fracture can
occur under normal physiological stress. Partial
or total destruction of the anterior vertebral body
results in decreased load-bearing capacity of the
spine. How and when pathological fracture
occurs is generally determined by the size and
location of the tumour, the extent of tumour
destruction, and the patients bone mineral
attenuation [14]. The threshold for pathological
fracture can be accurately predicted by
4315
PET
Finally, positron emission tomography (PET)
employs tagged molecules to detect regions of
increased uptake. F-fluoride detects regions of
increased fluoride uptake and thereby serves as
a marker of skeletal re-modelling. Fluorodeoxyglucose (FDG) aggregates in regions of
increased metabolic activity in the skeleton and
soft tissues and signals regions of neoplastic,
inflammatory, or infectious activity. Both
F-PET and FDGPET scans have been shown to
be useful in staging systemic disease in cancer
patients in combination with CT and MRI. All of
the nuclear modalities provide better definition of
lytic and mixed lesions in comparison to sclerotic
lesions. This is likely related to the acellular and
thereby hypometabolic nature of sclerotic
lesions.
Biopsy: percutaneous vertebral biopsy can be
performed and it is indicated to confirm metastatic
disease in a patient with a known primary tumour,
to evaluate a suspicious radiographic lesion, or to
provide tissue for hormonal evaluation.
Percutaneous biopsy is better performed using
a large biopsy needle in order to obtain
E. Caceres Palou
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Fig. 5 Posterior decompression and instrumentation in acute metastasis with epidural metastases mass
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E. Caceres Palou
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Steroids
The use of glucocorticoids [18] in the treatment of metastasis with neurological thought
to be due to oedema probably has an effect. Of
all these, dexamethasone is most recommended
for its minimal effect on the retention of salt
and the relative potency over other corticosteroids. Two types have been recommended-low
dosage (4 mg every 6 h) or high (100mgrs
initial ev, and 24 mgrs oral every 6 h for
4 days). There are however serious potential
complications of therapy with steroids, which
include psychosis, diabetes, increased susceptibility to infections and gastro-intestinal
bleeding.
Chemotherapy
Krakoff [19] defines three types of tumoral
sensitivity to chemotherapy (8):
Highly sensitive: Childhood cancers (like acute
lymphocytic leukaemia, Wilms tumour,
Ewings tumour, retinoblastoma, and rhabdomyosarcoma). Hodgkins lymphoma, Carcinoma of the testis, Choriocarcinoma,
Burkitts tumour or Acute promyelocytic leukemia. In many centres chemotherapy is considered the primary treatment for patients with
Radiation Therapy
Can be used for treatment of bone pain or neurological deficits in the absence of mechanical compromise. In the last years some advances in
imaging technology and computerized treatment
planning have allowed the safe delivery of highdose radiation (spinal radiosurgery) and local
control pass to figures around 7090 %
depending the histology of the tumour [20].
Conventional Radiotherapy
Strong recommendation with moderate- quality
evidence that conventional fractionated RT is an
appropriated initial therapy option in SM with no
relative contra-indications (spinal instability,
prior irradiation, radio-resistant histology and
high-grade spinal cord compression).
Radiosurgery
Strong recommendation with low-quality evidence that radiosurgery should be considered
over RT for SM in the setting of oligometastatic
disease and/or radio-resistant histology with no
relative contra-indication.
Surgical Management
Surgical treatment of vertebral metastases is
a real challenge for a spine surgeon. There are
many strategies currently available for this
disease, starting with observation to aggressive
en bloc spondylectomy. Furthermore, it is not
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Operative Technique
All patients with mechanical instability require
a spinal stabilization procedure because radiation
therapy and chemotherapy do not restore spinal
stability. Depending on the degree of instability
and tumour infiltration, instrumented stabilization or vertebroplasty can be performed. Finally
some hard selection cases could be treated with
en bloc resection.
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Fig. 6 (continued)
E. Caceres Palou
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E. Caceres Palou
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En Bloc Resection
The main question is: Which is the role of en bloc
surgery for metastatic tumours of the spine?
Theoretical evidenc for en bloc resection but
there is a paucity of published experience in SM
treatment and the majority of these articles are
about renal cell carcinoma (Fig. 6). This is
a comparative table between debulking and en
bloc resection of solitary SM We conclude and
we follow this procedure in patients suffering
from single spinal metastasis deriving from
the primary tumour, with a long life expectancy
and already treated, but we also need to include:
tumour size, location, WWB surgical score
classification in order to know if its possible
to do it.
Summary
The spine is the most common site of skeletal
metastases. The evolution of surgical methods,
medical treatment, and radiation therapy has led
to improved survival, functional status, and
quality of life for patients with cancer. The role
of surgery in the treatment of patients with spinal
metastases has evolved over time.
The treatment goals of spinal metastases
include the preservation and restoration of
neurological function and spinal stability. Modern imaging modalities provide accurate methods
of tumour diagnosis. A variety of approaches and
stabilization techniques are available and should
be tailored to the location of the tumour and
systemic co-morbidities.
As part of multidisciplinary treatment that
includes radiation therapy and chemotherapy,
surgery provides an effective method of
restoration and preservation of neurological
function and spinal stability for patients with
metastatic spinal tumours.
References
Complications
The rate of complications from surgical procedures on tumour affected vertebral bodies is
high. The majority of the patients are old-aged
and their general condition is reduced.
Hence particularly the mobility after surgery
of these patients is limited. Pulmonary
complications, thrombosis and decubitus are
frequent consequences. Steroid therapy and/or
radiotherapy often is/are the reason(s)
for wound healing disorders. Patients with
very vascular tumour metastases (renal
cell carcinoma, plasmocytoma) in many cases
suffer from intra-operative complications and
post-operative hematomas. Researching the
literature, the overall rate of complications
from surgical procedures on a tumour af- fected
spine with metastases is high.
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17. Rivas A, Caceres E, Ubierna MT, Llado A, Ramrez
M, Salo GY, Molina A. Fiability, sensibility,
especificity and safety of percutaneous CT Guided
vertebral
biopsy.
Rev
Ortop
Traumatol.
2007;51:24555.
18. Vecht CJ, Haaxma-Reiche H, van Putten WL, et al.
Initial bo- lus of conventional versus high-dose
dexamethasone in meta- static spinal cord compression. Neurology. 1989;39:12557.
19. Krakoff IH. Systemic treatment of cancer. CA Cancer
J Clin. 1996;46:13741.
20. McQuay HJ, Collins SL, Carroll D, Moore RA.
Radiotherapy for the palliation of painful bone
metastases. Cochrane Database Sys Rev. 2000:1793.
21. 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;366(9486):6438.
22. Fourney DR, Schomer DF, Nader R, et al. Percutaneous verte- broplasty and kyphoplasty for painful
vertebral body fractures in cancer patients.
J Neurosurg. 2003;98 Suppl 1:2130.
23. Gerszten PC, Germanwala A, Burton SA, et al.
Combination ky- phoplasty and spinal radiosurgery:
a new treatment paradigm for patho- logical fractures.
J Neurosurg Spine. 2005;3(4):296301.