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

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Presentation on theme: "Modern Treatment of Spinal metastases Maxwell Boakye, MD MPH FACS FAANS Associate Professor of Neurosurgery Nelson Endowed Chair Center for Advanced Neurosurgery,"— Presentation transcript:

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 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 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

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12 Epidural Compression: Surgery is superior to radiation Patchell et. al, Lancet Vol 366: , 2005

13 Patchell study

14 Surgery vs. radiation-Patchell

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

16 Surgical complications

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

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19 Emerging Treatment Patterns Vertebral augmentation – Vertebroplasty – Kyphoplasty Radiosurgery Combined kyphoplasty and radiosurgery

20 KYPHOPLASTY

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22 CAFÉ TRIAL

23 CAFÉ trial

24 Berenson et. Al., Lancet Oncology 2011 Mar;12(3):

25 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!!

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28 Other radiosurgery systems

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31 Concept of Separation surgery

32 Separation surgery

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35 DECISION MAKING Who should be operated on? Frameworks for prognosis Algorithms and Decision aids

36 Tokuhashi score 9:ExcisionSurvival > 12 months 5:PalliativeSurvival < 3 months

37 Decision Making-NOMS criteria Neurologic Oncologic Mechanical Systemic

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

39 Neurologic-Classification of Epidural compression

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

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

42 Mechanical Instability

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44 Systemic factors

45 SINS score Ranges , Stable 7-12, indeterminate, possibly impending instability Instability Surgical consultation is recommended for SINS score > 7. Fisher CG, Spine Vol 35(22): , 2010

46 Oncologic factors-Impact of Comorbidities

47 Oncologic and Systemic factors-survival

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50 Predictors of Survival VAriableHazard ratio95% CIP-value Age Ambulatory status Cervical mets Comorbidity Epidural compression Pathologic fracture Radiosensitivity < Radiotherapy Urinary incontinence Visceral mets

51 NOMS decision framework. Bilsky M, Hematol Oncol Clin N Am 20 (2006) 1307–1317

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