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Metastatic Spine Disease Moderator Jack Rock, MD Department of Neurosurgery Henry Ford Health System.

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Presentation on theme: "Metastatic Spine Disease Moderator Jack Rock, MD Department of Neurosurgery Henry Ford Health System."— Presentation transcript:

1 Metastatic Spine Disease Moderator Jack Rock, MD Department of Neurosurgery Henry Ford Health System

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

3 No detectable weakness Hypereflexia in lower extremities Babinski Case Presentation

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, MD Professor, Director of Radiosurgery Radiation Oncology and Neurosurgery Henry Ford Health System

8 TreatmentProsCons SteroidImmediate neurologic reliefShort duration External beam radiotherapy Main-stay treatment Pain relief Neurologic improvement Non-invasive Protracted course Pain recurrence Neurologic progression Knocks down bone marrow Surgery (Circumferential decompression, Laminectomy) Rapid neurologic improvement Tissue diagnosis Invasive Reconstruction is needed Long recovery time Needs radiotherapy Vertebroplasty Pain relief Improve spinal stability? No tumor control Chemical leakage Treatment of spine metastasis  cord compression Radiosurgery Rapid pain & neurologic relief Spinal cord decompression Non-invasive Convenience Bone marrow sparing Cannot correct compression fracture or Spine instability

9 Radiotherapy 30 Gy in 10 fractions Radiosurgery

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

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

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

13 65  14% Epidural volume reduction Thecal sac patency 55  3 % 77  3 % Decompressive Radiosurgery Epidural tumor size0.84  0.07 mm  0.06 mm 2 Thecal sac area1.06  0.06 mm  0.10 mm 2

14 Patchel’s Phase III TrialRyu’s Phase II Trial S+RTRT AloneRadiosurgery Overall Ambulatory rate 84% (42/50) 57% (29/51) Overall Intact rate 81% (50/62) Duration ambul122 d13 d Ambulatory rate in ambulat pts 94% (32/34) 74% (26/35) Intact rate in intact pts 88% (31/35) Ambulatory rate from nonambulat 62% (10/16) 19% (3/16) Intact rate from deficit 59% (19/27) Comparison of Neurological Outcome

15 Neurological Outcome by Radiosurgical Decompression Neuro before radiosurgery Neuro after RSNo deficitDeficit Normal31 pts16 pts Improved -3 pts Stable-3 pts Progressed4 pts5 pts Total35 pts27 pts 19% (12/62) Progress 81% of total pts improve (Ryu, Cancer 2010)

16 Radiographic Grade 0 I II IV, V III Dual grading system of metastatic epidural compression aNo abnormality bMinor symptoms (eg, pain, radiculopathy, sensory change) cFunctional paresis Muscle power ≥ 4/5. -nerve root sign or spinal cord sign -functional in the upper extremity -ambulatory in the lower extremity dNon-Functional paresis Muscle power ≤3/5. -non-functional in the upper extrem -non-ambulatory in the lower extrem eParalysis, Incontinence Neurological Grade 0Spine bone involved only IThecal sac impinged IIThecal sac compressed IIISpinal cord impinged IVCord displaced/compressed, CSF visible between cord and tumor, Partial block VCSF not visible, Complete block

17 Treatment for Canal Compromise at Henry Ford 7/08 10/08 Renal cell ca, T12, Grade 4b, 18 Gy 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 For surgery Significant neurological deficit (≤ 3/5 motor power) Compression fracture with bony retropulsion Spinal instability Grade 2a, Neuro intact 3 mon

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 metastases Recommendations 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 TranspedicularCostotransversectomy Lateral Extracavitary –Lateral/Anterior RetroperitonealTransthoracic

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 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 Oct;1(3):

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

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

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 –Preop RT increases complication rate of surgery

38 Surgery for Spine Metastases Current/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 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): , 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 Jun;49(6): 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 Oct;1(3):

40 Bone Augmentation For Non-surgical Mets Yahya Albeer, MD Department of Radiology Department of Radiology Henry Ford Health System

41 Metastatic Bone Disease Treatment 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 Disease Available Treatments - Other 1 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.



45 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: Fourney et al J Neurosurg (Spine 1) 2003; 98:21-30 J Clin Neurosci 2011 Jun;18(6): Epub 2011 Apr 19. J Surg Oncol 2010 Jul 1;102(1):43-7. Radiology 2010;254(3): AJNR 2007;28:

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

47 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

48 Thank you

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