Metastases of spine
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METASTATIC LESIONS OF SPINE
Dr. Sushil Paudel
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Metastatic tumour - most common malignancy of bone
Spine - most common site of osseous metastases
5-10% of the patients with cancer develop spine metastases*
All age groups with highest age incidence in between 40 and 65 years
Male:Female – 3:2
*Ries LAG, Melbert D, Krapcho M, et al, eds. SEER Cancer Statistics Review,1975–2005. National Cancer Institute. Bethesda
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LOCATION◦ Thoracic spine (60-
80%)◦ Lumbar spine (15-
30%)◦ Cervical spine (<10%)
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PRIMARY*◦ Unknown(33%)◦ Breast (21%)◦ Lung (14%)◦ Prostate(8%)◦ Gastrointestinal (5%)◦ Thyroid (3%)
*Ries LAG, Melbert D, Krapcho M, et al, eds. SEER Cancer Statistics Review,1975–2005. National Cancer Institute. Bethesda
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Basis of anatomic location* Intradural - 5%
◦ Intramedullary◦ Extramedullary – tertiary
drop metastases
Extradural - 95%◦ Pure epidural – rare◦ Arising from the vertebrae -
most frequent
*Perrin RG, Laxton AW. Metastatic spine disease:epidemiology, pathophysiology, and evaluationof patients. Neurosurg Clin N Am 2004;15:365–373
Intramedullary extradural metastases entrapped in cauda equina
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Metastatic properties of primary neoplasia Anatomic properties of the host organism Biologic properties of the skeletal host
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Posterior half of the body is seeded first, anterior half, pedicles and lateral masses are involved later
Local spread to adjacent vertebra Spread to epidural space Induce osteoblastic or lytic lesions, diffuse
osteopenia or variable combination Replacement of marrow tissue with
neoplasm, progressive collapse and finally spinal instability
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Pain – 85%◦ Constant and
localised◦ Radicular◦ Axial
Spinal deformity Neurologic deficit Constitutional
symptoms
RED FLAG features– Gradual onset, progressive, constant, night time or recumbency pain and axial pain exaberated by movement in all directions
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History Physical examination Laboratory studies Imaging studies
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HISTORY◦ Nature of patient’s symptoms and their onset◦ Exposure to possible carcinogens◦ Family history◦ Review of other systems
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PHYSICAL EXAMINATION◦ Comprehensive◦ Should palpate for
masses diagnostic of a primary breast, thyroid, prostate, or rectal carcinoma
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LABORATORY STUDIES◦ Complete blood counts◦ Serum chemistry◦ ESR◦ Serum and urine protein
electrophoresis◦ Serum tumour markers-
PSA, CEA, CA 19-9, AFP◦ Mammography◦ Bone marrow biopsy
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IMAGING STUDIES Plain radiographs Bone scan CT scan of chest,
abdomen, pelvis and of the suspicious area
MRI PET scan
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History and physical examination
Local plain films, chest radiographsand Laboratory tests
Suspicious or no lesion
Bone scan
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Bone scan
Polyostotic Monostotic
CT scan/MR imaging Perform biopsy
Impending fracture
No impending fracture
Perform biopsy and stabilise
Observe, radiate or perform biopsy
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Biopsy
Primary sarcomaMetastatic carcinoma
Refer to sarcoma surgeon
Renal or thyroid primary
Non Renal or thyroid primary
Treat as indicated
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History and physical examinationChest radiographs and Laboratory tests
MyelomaPrimary not identified
Primary identified
Stage and as indicated
Bone scan, CT scan of chest, abdomen
and pelvis
Skeletal survey; Refer to medical
oncologist
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Bone scan; CT scan of chest, abdomen and pelvis
Primary identified
Solitary lesion and primary
not identified
Multiple bone lesions and Primary n0t identified
Assume sarcoma;Refer to
orthopaedic oncologist
Perform biopsy on most appropriate
site
Stage and treat as
indicated
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Diagnostic imaging
Biopsy
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PLAIN RADIOGRAPHS◦ Location◦ Pattern of bone destruction◦ Vertebral collapse◦ Winking owl sign ◦ Difficult to detect early lesions
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BONE SCAN◦ Superior sensitivity◦ Extent of dissemination◦ Define the most accessible lesion
to biopsy in cases of unknown primary
SPECT
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COMPUTED TOMOGRAPHY◦ Improved specificity ◦ Sensitive to alterations in
bone mineralisation◦ Osseous details ◦ Evaluation of cortical
penetration
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MAGNETIC RESONANCE IMAGING◦ Superior sensitivity and specificity◦ Method of choice to evaluate spine ◦ Define the intramedullary, intradural and extramedullary lesions ◦ Extent of the lesion ◦ Differentiation from other
pathologies such as infection and osteoporotic ◦ Fat suppression and Gadolinium
enhancement to improve the delineation
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POSITRON EMISSION TOMOGRAPHY◦ Uses Flourine-18-Flouro deoxy
glucose◦ MRgIc calculation by Patlak
analysis in ROI◦ Detection of primary and
metastatic tumours◦ Recurrences of tumour◦ Differentiation of osteoporotic
VCF from pathologic VCF’s
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Tissue diagnosis of lesion guides the treatment
FNAC or needle biopsy Core biopsy Incisional biopsy Excisional biopsy
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PER CUTANEOUS APPROACHES FOR BIOPSY
Posterior cervical
C 1 – 3= Transoral
Sub axial cervical
Anterior or posterior to sternocleidomastoid
Thoracic and Lumbar
Transpedicular or Postero lateral
Sacral Posterolateral
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DIRECTED TO PRIMARY
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LUNG CANCER Metastatic stage IV – dismal
prognosis, median survival < 6 months
◦ Small cell LC Chemotherapy Radiotherpy
◦ Non small cell LC Combined chemo and
radiotherapy Resection of the tumour with
vertebrectomy
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PROSTATE CANCER Hormone withdrawal –
bilateral orchidectomies or androgen deprivation (LHRH agonists, flutamide etc)
Radiation therapy Chemotherapy Surgery Average survival around
12 months
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BREAST CANCER Metastatic cancer –
median survival 3 years Chemotherapy Hormonal therapy –
Tamoxifen Bisphosphonates
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THYROID CANCER Thyroidectomy followed by
iodine – 131 at therapeutic doses
Palliative radiotherapy Overall 10 year survival
rate – 35%
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RENAL CELL CARCINOMA Metastatic – median
survival 6 to 9 months Combined
chemo/immune therapy Radiotherapy Pre operative
Embolisation and Surgery
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DIRECTED TO SPINAL LESION
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Early 1900’ s – surgical treatment such as decompressive laminectomy
1953 - first patient was treated with a linear accelerator
1980’ s – advent of spinal implants Recent developments - Intensity-modulated
radiation therapy (IMRT), stereotactic radiosurgery, and stereotactic radiotherapy
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Life expectancy Biopsy – Histology to predict the response
to non operative management Stability Clinical presentation – Pain and Neurological
status
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Analgesic treatment Physical therapy and bracing Bisphosphonates Vertebroplasty or Kyphoplasty Radiofrequency ablation Radiation therapy Surgical stabilization in patients with life
expectancy of more than 3 months
PATIENTS PRESENTING WITH PAIN AND NO NEUROLOGICAL DEFICIT
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ANALGESIC TREATMENT Three Step model of analgesia
◦ NSAIDS◦ Short acting opioids◦ Pure opioid agonists
Disease-modifying therapies, coanalgesic/adjuvant administration, and interventional strategies (cognitive, behavioral, physiatric etc)
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BISPHOSPHONATES Treat hypercalcemia Potent inhibitors of normal and
pathological bone resorption. Antiangiogenic effects and
Antitumoral activity*PHYSICAL THERAPY AND BRACING Orthoses Bracing
*Diel IJ, Solomayer EF, Costa SD, et al: Reduction in new metastases in breast cancer with adjuvant clodronate treatment. N Engl J Med 339:357–363, 1998
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Emergency whole spine MRI
Dexamethasone
Radiosensitivity+ -
Unstable spine
VertebroplastyOr
Kyphoplasty
Radiotherapy
Neurological deficit<24 hrs
Surgical candidate
_
+
-
Surgical decompression and stabilization followed by
radiotherapy
+
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CORTICOSTEROIDS Should be prescribed in
all patients presenting with neurological deficit◦ High dose
dexamethasone◦ Standard dose ◦ Methyl prednisolone
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General indications
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EXTERNAL BEAM RADIOTHERAPY◦ Pain-Single fraction radiotherapy◦ Neurological deficit-short course
and long course regimens Intra operative brachytherapy Cobalt-60 teletherapy Injectable radioisotopes Megavoltage therapy Proton/neutron/electron
bombardment
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IMRT, STEREOTACTIC RADIOSURGERY AND STEREO TACTIC RADIOTHERAPY*◦ Deliver high doses safely◦ Possible to irradiate spine without affecting spinal
cord
*De Salles AA, Pedroso AG, Medin P, Agazaryan N, Solberg T,Cabatan-Awang C, et al: Spinal lesions treated with Novalisshaped beam intensity-modulated radiosurgery and stereotacticradiotherapy. J Neurosurg 101 (3 Suppl):435–440, 2004
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(A) Target planning image. The thick dark pink line surrounds the target volume. The thick dark green line represents the thecal sac (main organ at risk). The remaining lines represent isodose lines. (B) Dose-volume histograms demonstrating steep falloff of radiation, with high doses being applied to the lesion and a low volume of the thecal sac being exposed to significant dose.
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SYSTEMIC RADIOISOTOPE THERAPY◦ Strontium – 89, Samarium -
153 and Rhenium – 186◦ Affinity to osteoblastic bone ◦ Local antitumour activity
and analgesic affect*
*Serafini AN: Systemic metabolic radiotherapy with samarium-153 EDTMP for the treatment of painful bone metastasis. Q J Nucl Med 45:91–99, 2001
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Injection of PMMA into the involved vertebral body under fluoroscopic guidance.
Reinforcement of the bone and stabilization of anterior column relieves pain
PMMA – Anti tumour activity
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MECHANISM OF PAIN RELIEF*◦ Stabilization of microfractures◦ Reduction of mechanical forces ◦ Destruction of the nerve terminals by the
cytotoxicity of PMMA
*Cotten A, Dewatre F, Cortet B, et al. Percutaneous vertebroplasty for osteolytic metastases and myeloma: effects of the percentage of lesion filling and the leakage of methyl methacrylate at clinical follow-up. Radiology 1996;200:525–530
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Percutaneous introduction of a KyphX balloon Inflated to reduce the fracture and deflation Void filled with PMMA
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Low extravasation rate
Pain relief equivalent to that of vertebroplasty
Can restore the lost vertebral height
Can correct the sagital balance
Can use more viscous cement
Increases the vertebral body strength
Increases the vertebral body stability
Can provide tissue for diagnosis
ADVANTAGES
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Uses thermal energy to destroy the tumour cells
Combined treatment with vertebroplasty*
*Schaefer O, Lohrmann C, Markmiller M, Uhrmeister P, Langer M. Technical innovation: combined treatment of a spinal metastasis with radiofrequency heat ablation and vertebroplasty. Am J Roent 2003;180:1075–1077
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Radiofrequency Ablation Probe at T9Anterior-posterior (a) and lateral (b) fluoroscopic images of the radiofrequency ablation probe in the T9 vertebral body
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Radiofrequency ablation combined with vertebroplasty/kyphoplasty
Tumour debulking combined with VB augmentation ◦ Ablation using LITT (laser induced thermotherapy)
before cement placement *
*Ahn H, Mousavi P, Chin L, et al. The effect of pre-vertebroplasty tumor ablation using laser-induced thermotherapy on biomechanical stability and cement fill in the metastatic spine. Eur Spine J 2007;16:1171–78. Epub 2007 Apr 20
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A 71-year-old woman with undifferentiated cancer and a lesion at L4. B and C, A void is created in the vertebral body by debulking the spinal tumor using the plasma radio-frequency– based wand before vertebral body augmentation with bone cement. D–F, Axial (D and E) and sagittal (F) views by using MR imaging show excellent anterior placement
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Vertebral body augmentation combined with hardware*◦ Short segment pedicle screw fixation combined
with vertebroplasty/kyphoplasty in lieu of traditional long segment fusion
*Cho DY, Lee WY, Sheu PC. Treatment of thoracolumbar burst fractures with polymethyl methacrylate vertebroplasty and short-segment pedicle screw fixation.Neurosurgery 2003;53:1354–60, discussion 1360-61
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GOALS◦ Obtaining tissue in case
of an unknown diagnosis
◦ Relief of neurologic symptoms by decompression
◦ Relief of pain by stabilization and reconstruction of the spinal column
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Pre operative for vascular metastatic lesions such as renal cell, thyroid carcinoma, squamous and adenocarcinomas of lung
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Resection Decompression Reconstruction and stabilization
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Radiation- and chemotherapy-resistant tumors (e.g., squamous and renal
cell)
Acute or progressive spinal cord compression
Recurrent tumor in patients who have already received maximal doses of
chemotherapy/radiation
Pain associated with collapse in vertebral height of greater than 50%, a 50% kyphotic
deformity, or more than 70% of the vertebral body destroyed
Isolated metastases in which durable remissions can potentially be achieved (e.g.,
renal, breast, thyroid)
Impending fracture
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SCORING SYSTEMS Karnofsky score estimates a patient's ability
to carry out normal activities, work, and care for themselves.
The Tokuhashi index◦ Karnofsky index◦ Neurologic status◦ Metastatic disease◦ Cancer type◦ Surgical resectability.
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Total Tokuhashi score Life expectancy
0–4 <3 mo
5–8 <6 mo
9–12 >6 mo
Tokuhashi score is developed as an assessment tool to select the most suitable surgical procedure with respect to predicted prognosis
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Tomita classification- built on Enneking oncological system
Description of the affected site Metastatic extent
◦ Intracompartmental(1-3)◦ Extracompartmental(4-7)
1. Vertebral body
2. One or both pedicles
3. Lamina and spinous process
4. Epidural canal
5. Paravertebral area
6. Adjacent vertebra
7. Skip lesions
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Tokuhashi
score Life expectancy
Tomita
classification Surgical procedure (all receive radiation)
0–4 <3 mo 1–7 Laminectomy and stabilization
5–8 3–6 mo 1–7 Posterior decompression, stabilization, and
reconstruction
9–12 >6 mo 1–3 En bloc with vertebrectomy and 360-degree
reconstruction
4–6 Intralesional vertebrectomy and 360-degree
reconstruction
7 Posterior decompression and stabilization
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Location of the tumour Spinal instability Neurological status
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James weinstein model
Zones IB to IVB – Extraosseous extensions of the tumour beyond cortical boneZones IC to IVC - Associated regional or distant metastases
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• Zones I and II lesions - posterior or posterolateral surgical approach Zone III lesions – anterior surgical approach Zone IV lesions - combined anterior and
posterior approach
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SURGICAL APPROACHES LEVEL ANTERIOR POSTERIOR
Upper cervical Transoral, Extraoral, Extreme lateral
Midline
Lower cervical Southwick Robinson Midline
Cervicothoracic Sternal splitting, Low costotransversectomy
MidlineCostotransversectomy
Thoracic ThoracotomyCostotranversectomy
CostotransversectomyTranspedicular
Thoracolumbar 11th rib extrapleural retroperitoneal
MidlinePosterolateral
Lumbar RetroperitonealTransabdominal
Midline,TranspedicularPosterolateral
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RECONSTRUCTION AND STABILIZATION◦ Anterior◦ PosteriorSubclassified according to the level
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THORACIC SPINE Disease involving vertebral body at 1 or 2
levels- Transthoracic vertebrectomy and anterior reconstruction
Single stage posterolateral decompression and stabilisation – patients with specific contraindication to thoracotomy
Significant kyphosis with VB collapse, disease involving DL junction – posterior stabilization with anterior reconstruction
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Inclusion of significant portion of chest wall in tumour resection – posterior stabilization to prevent the risk of kyphoscoliosis
Cases of tumours involving VB posterior elements and chest wall – combined approach for resection and VB reconstruction, anterior and posterior stabilization
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INSTRUMENTATION Fixation using rods and screws Vertebral body reconstruction – metal cage,
cement, ceramic spacer, or grafts( autologous or allograft)
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57 year old female of lung carcinoma with metastases D5 underwent circumferential tumor resection and simultaneous anterior and posterior reconstruction by combined approach.
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LUMBAR SPINE Standard retroperitoneal approach –
excellent exposure Single level L1-3 disease – vertebrectomy
and anterior reconstruction Disease limited to L5 – posterolateral
decompression and stabilisation Multilevel disease – palliative posterolateral
decompression
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LUMBOSACRAL JUNCTION AND SACRUM Resection and reconstruction by pedicle screws
and rods by modified Galveston technique
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Cure is not the goal
Multidisciplinary approach
Surgery vs Radiotherapy*
Management often not clear cut
Patchell RA, Tibbs PA, Regine WF et al. Direct decompressivesurgical resection in the treatment of spinal cordcompression caused by metastatic cancer: a randomisedtrial. Lancet 2005;366:643-8.
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Adult and Pediatric spine, 3rd edition Spinal Extradural metastases; Review of
current treatment options.CA Cancer J Clin 2008;58;245-259
Spinal instability and deformity due to neoplastic conditions.Neurosurg Focus 14 (1):Article 8, 2003
Bone metastases.Tumors
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