management of metastatic spinal neoplasms · 2018-11-20 · radiation resistant tumors low...
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Management of Metastatic Spinal Neoplasms
Sanjay Yadla, MDJune 13, 2008Department of NeurosurgeryThomas Jefferson University
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EpidemiologyDiagnosis/ImagingManagement
Radiation vs SurgerySurgical IndicationsSurgical ApproachSurgical Strategies
Management of Spinal Metastases
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Metastatic Spinal Neoplasms
18,000 New Cases/YearMost frequent site of bone metastasis1 to 5% of all cancer patients will present with cord compression90% of patients will have spine metsat the time of death
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Cervical – 10%
Thoracic – 70%
*T4 to T11
Lumbar – 20%
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Tumors That Disseminate to the Spine
BreastLung ProstateRenal CellMyeloma, Lymphoma, GI
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Metastatic Tumors: Breast CA
Most Common Source of Mets to SpineClinical Course Varies GreatlySpread via the Azygous Venous System
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Metastatic Tumors: Lung
Spine Lesions often MultipleAdenoCAs are the most common subtypeCancer cells enter the pulmonary venous system -> Heart -> Skeletal spreadDirect Spread
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Sites of Metastases
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Signs & Symptoms: Pain
Most Common Presenting SymptomOccurs in 83 to 95%Three Classic Syndromes
LocalMechanicalRadicular
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Local Pain
Aching, NocturnalPeriostealStretchingLocal Inflammatory ProcessResponds to Steroids and Anti-Inflammatories
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Mechanical Back Pain
Instability of the Spinal ColumnPosturally RelatedWorsens as day progressesRelief with change in position or external bracingRefractory to narcotics, and anti-inflammatories
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Radicular Back Pain
Compression or Irritation of Exiting Nerve RootDermatomal distributionStabbing, Shooting
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Median Time to Diagnosis – 2 MonthsNew Onset Back/Neck PainThoracic Pain
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Signs & Symptoms
Anorexia, unexplained weight lossPalpable mass on examination
ParaspinalRectal
Myelopathy – poor coordination, Hoffman’s sign
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Radiographic Studies: X-ray
Most are OsteolyticBreast/Prostate can be Osteoblastic“Winking Owl” SignSubtle Clue: Indistinct Posterior VB MarginOther Osteolytic Lesions: EosinophilicGranuloma, Plasmacytoma, Hemangioma, Osteomyelitis, Brown Tumor of HyperPTH
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“Winking Owl” Sign
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Radiographic Studies: CT
Multiple LyticLesionsIrregular/Non-Sclerotic MarginsCortical BreakthroughEpidural Extension
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Radiographic Studies: MRI
Contrast Enhanced MRI: StandardComplete Spinal AxisDistortion of CSF SpacesParaspinal/Epidural MassesOccult Mets
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Diagnosis: Biopsy
Open, Incisional, ExcisionalNeedle Biopsy:
Small SampleSampling Error
Non Diagnostic Rate 30-40%
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Therapeutic Decision Making
General Medical ConditionTumor Type/RadiosensitivityTumor Stage/Life ExpectancyPrevious TxNeurologic ConditionSpinal Involvement/InstabilityPatient/Family Wishes
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Therapy Algorithm
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Treatment
Medical ManagementPreoperative EmbolizationRadiotherapySurgery
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Treatment: Medical Mgmt
Steroids may improve pain relief and possibly neurological functionNo optimum dosing scheduleSorenson et al (1994 Euro J Cancer)
Randomized trial of 57 patientsHigh dose dexamethasoneAfter six months, 59 vs 33% ambulatory11% with significant side effects
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Adjunct Therapy: Embolization
Safe, effectiveFacilitate tumor resectionRenal Cell CAAvoid major spinal feeding arteries (Adamkiewicz)
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Treatment: Radiotherapy
Diminished risk of MorbidityMay be initial choice of mgmtPain control in 50 to 90%Neurologic Improvement in 40%
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Radiotherapy Limitations
Harmful Side Effects to local tissue/skinRadiation resistant tumorsLow tolerance of spinal cord to XRTMets progress or recurRadiation Induced MyelitisTolerance dose 5/5 is 5 GyTolerance dose 50/5 is 7 Gy
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The Dark Ages
Prior to 2003, only one Class I study was published in the peer-reviewed literatureYoung et al. Journal of Neurosurgery, 53: 741-748, 1980.Randomized prospective comparison:
16 pts underwent laminectomy/radiation13 pts underwent radiation alone
Mean followup: 4 months
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Young et al.
No significant difference was found in the effectiveness of the two treatment methods in regard to pain relief, improved ambulation, or improved sphincter function.
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The Dark Ages: Laminectomy
Spine mets are most often located anteriorly in the VBPoor for resection/decompressionMay predispose patient to spinal instability
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Dark Ages Continued
In many centers patients were referred for surgery:
After Chemotx and XRT had failedEmergency decompression with acute and rapid neurologic failureConsiderable morbidity
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Postoperatively, 82% were improved in terms of ambulatory status and pain relief
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Dark Ages Continued
Uncontrolled Series and MetanalysisPatient Selection biasHeterogenous tumor typesUnclear inclusion criteriaImprecise endpoints
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Patchell RA, et al.
Randomized, non-blinded prospective trial (n=123)Surgery and XRT vs XRT alonePrimary Endpoint: Ability to walkSecondary Endpoints: Urinary continence, muscle strength, functional status, survival time, need for steroids/opioids
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Patchell RA, et al.
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Patchell RA, et al.
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Patchell RA, et al.
Post-treatment ambulatory rate in the surgery group was 84% and 57% in the radiation group (p=0.001)Patients retained the ability to walk for 122 days in the surgery group versus 13 days in the radiation group (p=0.003)Median hospital stay was 10 days in both the surgery and radiation group (0=0.86)
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Patchell RA, et al.
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Review of Literature (1964-2000)
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Indications for Surgery
Failure of Radiation TherapyUnknown DiagnosisPathologic Fracture/DislocationParaplegia: Rapidly Progressing/Far Advanced
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Precautions for Surgery
ElderlyDebilitatedPoor Nutritional StatusImpaired Immune FunctionLow Bone Marrow Reserve
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Factors Determining the Surgical Approach
Tumor LocationSpinal LevelTumor ExtentBony IntegrityPatient Debility
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Surgical Approaches
Anterior ApproachesPosterior ApproachesPosterolateral Approaches
TranspedicularCostotransversectomyLECA
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Anterior Approaches: Craniocervical Junction
Foramen magnum, C1, C2, structures contained withinTransoral-transpalatopharyngealapproachLateral Extrapharyngeal Approach
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Transoral-transpharyngeal Approach
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Transoral-transpharyngeal Approach
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Transoral-transpharyngeal approach
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Transoral-transpharyngeal approach
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Anterior Approaches: Thoracic Spine
Upper segments (T1-T4) may be particularly challengingMay require Sternotomy or ThoracotomyT5-T10 approached via right (to avoid the aortic arch) or left (difficult to mobilize liver
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Interaortocaval Subinnominate Window
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Anterior Approaches: Cont’d
Thoracolumbar Junction (T11-L1): Thoracotomy and Retroperitoneal ApproachLumbar (L2-L4): Retroperitoneal or Transabdominal ApproachIntra-abdominal contents at riskPatients should be expected to have post-op ileus
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Posterior Approaches
Resultant Instability requires Instrumentation and FusionIn the upper thoracic spine the scapula must be mobilized.Working distance can be extensiveAt T11-12 the diaphragm limits the working space
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Transpedicular Approach
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Costotransversectomy
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Lateral Extracavitary Approach
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Vertebroplasty/Kyphoplasty
Percutaneous injection of PMMAVertebroplasty – direct injection into the vertebral bodyKyphoplasty – Expandable balloon placed to create a cavityComplications: Leakage, Misdirection, PMMA Pulmonary Embolus
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Spine Metastasis: Summary
Spine Mets are not uncommon in patients with cancerSurgery and radiation therapy is superior to radiation therapy alone in selected patientsManagement of patients with spine metastases requires a multidisciplinary approach
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