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Metastatic Spine Disease

Metastatic Spine Disease. Moderator Jack Rock, MD Department of Neurosurgery Henry Ford Health System. 61 year old female History of breast Cancer, HTN Back pain for 1 week. Case Presentation. Case Presentation. No detectable weakness Hypereflexia in lower extremities Babinski.

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Metastatic Spine Disease

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  1. Metastatic Spine Disease Moderator Jack Rock, MDDepartment of NeurosurgeryHenry Ford Health System

  2. 61 year old female History of breast Cancer, HTN Back pain for 1 week Case Presentation

  3. Case Presentation • No detectable weakness • Hypereflexia in lower extremities • Babinski

  4. Case Presentation ( Please Choose appropriate case)

  5. Case Presentation What would you do?1-Medical treatment (Steroids, Pain Rx, Brace)2- Radiation therapy 3- Surgical treatment (laminectomy ,Fusion) 4- Bone augmentation for non-surgical mets

  6. Electronic Voting

  7. Treatment options for Spine Metastasis and Spinal Cord Compression Samuel Ryu, MDProfessor, Director of Radiosurgery Radiation Oncology and NeurosurgeryHenry Ford Health System

  8. Treatment of spine metastasis  cord compression

  9. Radiotherapy 30 Gy in 10 fractions Radiosurgery

  10. Phase II - Radiosurgery of Vertebral mets % Pain relief Months after RS Rapid Pain Relief Durable Pain relief Median time to pain relief 14 days 1-yr pain control 84% (Ryu et al. Pain Symp Manag, 2008)

  11. RTOG 0631 Randomized Phase II/III Study of Radiosurgery vs. EBRT for Localized Spine Metastasis (1) (2) (3) Solitary (1-3) spine metastasis Single arm lead-in (49 pts) Radiosurgery (16 Gy) 2:1 Randomized (240 pts) EBRT 8 Gy single dose Radiosurgery (16, 18 Gy) Follow-up 1. Pain score & QOL q month 2. Clinical and neuro exams q month 3. Imaging (MRI) q 2 months

  12. 50% 90% Control of Spinal Cord Compression 1/29/05 12/4/04 Breast cancer 16 Gy

  13. Epidural tumor size 0.840.07 mm2 0.410.06 mm2 Thecal sac area 1.060.06 mm2 1.390.10 mm2 Decompressive Radiosurgery Thecal sac patency 553% 773% 65  14%Epidural volume reduction

  14. Comparison of Neurological Outcome

  15. Neurological Outcome by Radiosurgical Decompression Neuro before radiosurgery Neuro after RS No deficit Deficit Normal 31 pts 16 pts Improved - 3 pts Stable - 3 pts Progressed 4 pts 5 pts Total 35 pts 27 pts 81% of total pts improve 19% (12/62) Progress (Ryu, Cancer 2010)

  16. 0 I II IV, V III Dual grading system of metastatic epidural compression Neurological Grade Radiographic Grade

  17. For surgery Significant neurological deficit (≤ 3/5 motor power) Compression fracture with bony retropulsion Spinal instability For radiosurgery Spinal cord compression in ambulatory patients (≥ 4/5 power) Imaging : No upper limit to the extent of spinal cord compression at this time Treatment for Canal Compromise at Henry Ford 3 mon 10/08 7/08 Grade 2a, Neuro intact Renal cell ca, T12, Grade 4b, 18 Gy

  18. Surgical Options for Spine Metastases Ian Lee, MD Staff Neurosurgeon Hermelin Brain Tumor Center Henry Ford Health System September 21, 2012 Comprehensive Spine Symposium

  19. Disclosures • None

  20. Surgery for Spine Metastases • Up to 35% of cancer patients will develop spine metastases • >20,000 new cases each year • Multiple levels of involvement in 40-70% • 12-20% of patients will present with spine symptoms as first manifestation of cancer

  21. Spine Metastases • Because most mets originate in the vertebral body, the site of compression is usually ventral • Tumor infiltration can also cause mechanical instability due to weakening of the bone

  22. Surgery for Spine Metastases • In the past, treatment was primarily radiation • Surgery sometimes offered, but without significant benefit • Retrospective studies demonstrated laminectomy resulted in neurologic improvement in a minority of patients and unsustained (Sorensen et al 1990, Constans et al 1983)

  23. Surgery for Spine Metastases • In addition, outcomes compared to EBRT were equivalent with or without laminectomy (Byrne 1992, Young et al 1980) • Thus, nihilistic attitude regarding role of surgery in metastatic spine disease

  24. Surgery for Spine Metastases In 1980’s, newer techniques of surgery allowed for more aggressive extirpation of disease and reconstruction

  25. Surgery for Spine Metastases RCT recently demonstrated superiority of sugical decompression + EBRT vs. EBRT alone (Patchell, Lancet 2005) Surgery + EBRT both preserved and regained ambulation better than EBRT First Class I study demonstrating advantage of surgery in treatment of metastatic disease

  26. Surgery for Spine Metastases • However, surgery is not without drawbacks • Morbidity as high as 20% in some series • Prolonged hospital time, rehabilitation time • Many patients cannot or are unwilling to tolerate surgery

  27. Surgery for Spine metastasesRecommendations • Indications for surgery: • Rapid neurologic deterioration • Mechanical instability • Intractable radicular pain/myelopathy • Compression due to bony retropulsion • Relatively limited extant of bony disease/compression • Relatively limited extraspinal disease/good performance status • Prognosis > 3 months

  28. Surgery for Spine Metastases • Surgical Approaches now available: • Posterior • Laminectomy • Posterolateral • Transpedicular • Costotransversectomy • Lateral Extracavitary • Lateral/Anterior • Retroperitoneal • Transthoracic

  29. Posterior approach Advantages: Familiar approach, less invasive/morbid Disadvantages: Does not directly address pathology, can cause instability Has fallen out of favor in the surgical treatment of metastatic disease from “Review: complications of surgery for thoracic disc disease”.Fessler RG, Sturgill M.Surg Neurol. 1998 Jun;49(6):609-18

  30. Anterior/Lateral Approach • Advantages: Directly address pathology • Disadvantages: Requires two-stage operation

  31. Posterolateral Approaches

  32. Surgical Approach • Posterolateral approaches (transpedicular, costotransversectomy) have become increasing popular • Allows for circumferential decompression and stabilization

  33. Posterolateral approach • Requires working around the spinal cord and sacrifice of nerve roots • Less common surgical approach, technically demanding • Small risk of cord infarct with nerve root sacrifice (esp. mid-lower thoracic)

  34. Surgical technique – Transpedicular/Costotransversectomy From Wang et al. March 2004.J Neurosurg Spine. 2004 Oct;1(3):287-98.

  35. Surgical technique – Transpedicular decompression From Wang et al. March 2004.J Neurosurg Spine. 2004 Oct;1(3):287-98.

  36. Surgical technique - Stabilization From Wang et al. March 2004.J Neurosurg Spine. 2004 Oct;1(3):287-98.

  37. Surgery for Spine Metastases Conclusions • For patients with good performance status and relatively limited disease, surgery should be strongly considered • Order of surgery vs RT should be considered as well • PreopRT increases complication rate of surgery

  38. Surgery for Spine MetastasesCurrent/Future Investigations • More aggressive surgical extirpation – e.g. en bloc spondylectomy • Does histology matter? • Less aggressive surgical decompression followed by SRS • Intraoperative radiotherapy • Phase III trials comparing SRS and surgery

  39. Spine Metastases - References Constans JP, de Divitiis E, Donzelli R, et al: Spinal metastases with neurological manifestations. Review of 600 cases. J Neurosurg 59:111–118, 1983 Sorensen S, Borgesen SE, Rhode K, et al: Metastatic epidural spinal cord compression. Results of treatment and survival. Cancer 65:1502–1508, 1990 Byrne TN: Spinal cord compression from epidural metastases. N Engl J Med 327:614–619, 1992 Young RF, Post EM, King GA: Treatment of spinal epidural metastases. Randomized prospective comparison of laminectomy and radiotherapy. J Neurosurg 53:741–748, 1980 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 Aug 20-26;366(9486):643-8 Ghogawala Z, Mansfield FL, Borges LF: Spinal radiation before surgical decompression adversely affects outcomes of surgery for symptomatic metastatic spinal cord compression. Spine (Phila. Pa 1976) 26(7), 818–824, 2001 Shiue K, Sahgal A, Chow E, Lutz ST, Chang EL, Mayr NA, Wang JZ, Cavaliere R, Mendel E, Lo SS: Management of metastatic spinal cord compression . Expert Rev Anticancer Ther. 10(5):697-708, 2010 Jacobs WB, Perrin RG. Evaluation and treatment of spinal metastases: an overview. Neurosurg Focus. 15;11(6):e10, 2001 Fessler RG, Sturgill. Review: complications of surgery for thoracic disc disease. M.Surg Neurol. 1998 Jun;49(6):609-18 Wang JC, Boland P, Mitra N, Yamada Y, Lis E, Stubblefield M, Bilsky MH. Single-stage posterolateral transpedicular approach for resection of epidural metastatic spine tumors involving the vertebral body with circumferential reconstruction: results in 140 patients. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004.J Neurosurg Spine. 2004 Oct;1(3):287-98.

  40. Bone Augmentation For Non-surgical Mets YahyaAlbeer, MD Department of RadiologyHenry Ford Health System

  41. Metastatic Bone DiseaseTreatment Goals • Reduce pain • Eradicate or reduce tumor when primary tumors are involved • Prevent neurologic complications • Treat pathologic fractures and prevent recurrent fracture

  42. Primary and Metastatic Bone DiseaseAvailable Treatments - Other1 • Radiation Therapy • Therapeutic: Reduce tumor in primary bone cancer • Palliative: Relieve pain related to bone metastasis • Surgery • To provide stability to compromised bone • To prevent neurologic deterioration after fracture 1. American Cancer Society, 2006.

  43. Results for Tumor Treatment • Kyphoplasty and Vertebroplasty similar • Pain relief in 75-85% of malignant lesions treated with vertebroplasty • The presence of epidural tissue does NOT preclude treatment* • Shimony et al Radiology 2004;232:846-853 • Fourney et al J Neurosurg (Spine 1) 2003; 98:21-30 • J Clin Neurosci 2011 Jun;18(6):763-7. Epub 2011 Apr 19. • J SurgOncol 2010 Jul 1;102(1):43-7. • Radiology 2010;254(3):882-890 • AJNR 2007;28: 570-574

  44. Q&A Jack Rock, M.D. Department of Neurosurgery

  45. Metastatic Spine Disease: Conclusions Most patients with metastatic disease involving the spine will be managed effectively either with observation or radiation For patients with spinal cord compression and rapidly progressing neurological deterioration or significant neurological compromise (i.e., non-ambulatory), tailored surgical decompression +/- fusion remains the gold standard For ambulatory patients with spinal cord compression, radiosurgery is proving to be effective in most cases As a treatment for painful spinal metastases vertebro- and kyphoplasty are effective augmentation procedures

  46. Thank you

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