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Metastatic Spine Disease

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Presentation on theme: "Metastatic Spine Disease"— Presentation transcript:

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

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

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

8 Treatment of spine metastasis  cord compression
Pros Cons Steroid Immediate neurologic relief Short 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 Improve spinal stability? No tumor control Chemical leakage 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 Phase II - Radiosurgery of Vertebral mets
Rapid Pain Relief Durable Pain relief Median time to pain relief 14 days 1-yr pain control 84% Months after RS % Pain relief (Ryu et al. Pain Symp Manag, 2008)

11 Randomized Phase II/III Study of
RTOG 0631 Randomized Phase II/III Study of Radiosurgery vs. EBRT for Localized Spine Metastasis Solitary (1-3) spine metastasis (1) (2) (3) 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 Control of Spinal Cord Compression
90% 50% 1/29/05 12/4/04 Breast cancer 16 Gy

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

14 Patchel’s Phase III Trial
Comparison of Neurological Outcome Patchel’s Phase III Trial Ryu’s Phase II Trial S+RT RT Alone Radiosurgery Overall Ambulatory rate 84% (42/50) 57% (29/51) Overall Intact rate 81% (50/62) Duration ambul 122 d 13 d Ambulatory rate in ambulat pts 94% (32/34) 74% (26/35) Intact rate in intact pts 88% (31/35) from nonambulat 62% (10/16) 19% (3/16) Intact rate from deficit 59% (19/27)

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

16 Neurological Grade Radiographic Grade I II IV, V III
Dual grading system of metastatic epidural compression Neurological Grade Radiographic Grade I II IV, V III a No abnormality b Minor symptoms (eg, pain, radiculopathy, sensory change) c Functional paresis Muscle power ≥ 4/5. nerve root sign or spinal cord sign functional in the upper extremity ambulatory in the lower extremity d Non-Functional paresis Muscle power ≤3/5. non-functional in the upper extrem non-ambulatory in the lower extrem e Paralysis, Incontinence Spine bone involved only I Thecal sac impinged II Thecal sac compressed III Spinal cord impinged IV Cord displaced/compressed, CSF visible between cord and tumor, Partial block V CSF not visible, Complete block

17 Treatment for Canal Compromise at Henry Ford
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 3 mon 10/08 7/08 Renal cell ca, T12, Grade 4b, 18 Gy Grade 2a, Neuro intact

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 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 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 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 - 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.



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 Jun;18(6): Epub 2011 Apr 19. J Surg Oncol Jul 1;102(1):43-7. Radiology 2010;254(3): AJNR 2007;28:

46 Jack Rock, M.D. Department of Neurosurgery
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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