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