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Modern Treatment of Spinal metastases

Modern Treatment of Spinal metastases. Maxwell Boakye , MD MPH FACS FAANS Associate Professor of Neurosurgery Nelson Endowed Chair Center for Advanced Neurosurgery, University of Louisville. My Background. Neurosurgeon Residency 2002

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Modern Treatment of Spinal metastases

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  1. Modern Treatment of Spinal metastases Maxwell Boakye, MD MPH FACS FAANS Associate Professor of Neurosurgery Nelson Endowed Chair Center for Advanced Neurosurgery, University of Louisville

  2. My Background • Neurosurgeon • Residency 2002 • Fellowships-complex spine-Emory and Spine Oncology-Sloan Kettering-2003 • Stanford-2003-2010-worked with cyberknife • Special interest in spine tumors and spine radiosurgery

  3. Goals • Epidemiology • Presentation • Imaging • Role of Surgery • Emerging Treatment paradigms • Decision making and Frameworks • Memorial Sloan Kettering NOMS criteria • Cases

  4. Epidemiology • 20000 new cases of metastatic epidural cord compression each year • 10% of cancer patients will develop spinal metastatic • About 70% of all cancer deaths occur in elderly patients aged over 65 • Postmortem studies metastases present in 90% of patients with systemic cancer

  5. Epidemiology • Number of elderly patients dying from cancer will double by 2030 • By age 2050, the number of newly diagnosed patients aged 85 will quadruple

  6. Signs and symptoms • Myelopathy-Motor, Sensory, Bowel/Bladder • Usually from epidural cord compression • Pain • Biologic • nocturnal/early morning-resolves during day-usually from tumor infiltration, Steroid responsive • Mechanical-movement related • Radicular-usually epidural disease in foramen • Other Symptoms e.g LOC or AMS from brain

  7. Imaging • X-rays • CT • MRI • PET

  8. Imaging findings • Imaging • Epidural disease only • Vertebral disease only • Vertebral disease with epidural • Cord compression • Mechanical instability • Pathological fractures • Single level, Multiple level, Distant metastases

  9. Treatment options • Surgery • Radiation therapy • Radiosurgery • Chemotherapy

  10. Main surgical approaches • Anterior Transthoracic, Retroperitoneal • Posterior Laminectomy • Posterior transpedicular, costotransversectomy approach

  11. Epidural Compression: Surgery is superior to radiation Patchell et. al, Lancet Vol 366: 643-648, 2005

  12. Patchell study

  13. Surgery vs. radiation-Patchell

  14. Surgery improves quality of life outcomes Quan et. Al., Eur Spine Journal 2011 Jun 26

  15. Surgical complications

  16. Price of surgery: High Morbidity and mortality • Mortality-5-6% • Complication rates-20-40%

  17. Emerging Treatment Patterns • Vertebral augmentation • Vertebroplasty • Kyphoplasty • Radiosurgery • Combined kyphoplasty and radiosurgery

  18. KYPHOPLASTY

  19. KYPHOPLASTY

  20. CAFÉ TRIAL

  21. CAFÉ trial

  22. Berenson et. Al., Lancet Oncology 2011 Mar;12(3):225-35.

  23. CYBERKNIFE RADIOSURGERY • The CyberKnife® a robotic manipulator to move a compact linear accelerator with six degrees of freedom • Real-Time Image Guidance Throughout the Treatment • Dynamic Motion Tracking • Allows for accuracy and conformality • Louisville is getting one!!

  24. Other radiosurgery systems

  25. Concept of Separation surgery

  26. Separation surgery

  27. DECISION MAKING • Who should be operated on? • Frameworks for prognosis • Algorithms and Decision aids

  28. Tokuhashi score 􀂃≥9:•Excision•Survival > 12 months 􀂃≤5:•Palliative•Survival < 3 months

  29. Decision Making-NOMS criteria • Neurologic • Oncologic • Mechanical • Systemic

  30. NOMS criteria • Neurologic-myelopathy, degree of epidural cord compression • Oncologic- radiosensitivity of tumor • Mechanical instability-movement related pain • Systemic disease and medical comorbidities

  31. Neurologic-Classification of Epidural compression

  32. Neurologic-Classification of epidural compression Bilsky M, Hematol Oncol Clin N Am 20 (2006) 1307–1317

  33. Oncologic-Radiosensitivity • –Myeloma & Lymphoma: most radiosensitive • –Prostate, Breast, Lung and Colon: moderately • –Thyroid, Kidney, Melanoma: not radiosensitive

  34. Mechanical Instability

  35. Systemic factors

  36. SINS score • Ranges 0-18 • 0-6, Stable • 7-12, indeterminate, possibly impending instability • 13-18-Instability • Surgical consultation is recommended for SINS score > 7. • Fisher CG, Spine Vol 35(22): 1221-1229, 2010

  37. Oncologic factors-Impact of Comorbidities

  38. Oncologic and Systemic factors-survival

  39. Predictors of Survival

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