Metastatic Spine Disease

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Metastatic Spine Disease
Moderator Jack Rock, MDDepartment of
Neurosurgery Henry Ford Health System
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Case Presentation

• 61 year old female
• History of breast Cancer, HTN
• Back pain for 1 week

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Case Presentation

• No detectable weakness
• Hypereflexia in lower extremities
• Babinski

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Case Presentation ( Please Choose appropriate
case)
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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
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Electronic Voting
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Treatment options for Spine Metastasis and Spinal
Cord Compression
Samuel Ryu, MDProfessor, Director of
Radiosurgery Radiation Oncology and
NeurosurgeryHenry Ford Health System
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Treatment of spine metastasis ? cord compression
Treatment 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 Pain relief 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
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Radiotherapy 30 Gy in 10 fractions
Radiosurgery
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Phase II - Radiosurgery of Vertebral mets
Rapid Pain Relief
Durable Pain relief
Median time to pain relief 14 days
1-yr pain control 84
(Ryu et al. Pain Symp Manag, 2008)
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RTOG 0631 Randomized Phase II/III Study
of Radiosurgery vs. EBRT for Localized Spine
Metastasis
Solitary (1-3) spine metastasis
Single arm lead-in (49 pts)
Radiosurgery (16 Gy)
21 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
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Control of Spinal Cord Compression
1/29/05
12/4/04 Breast cancer 16 Gy
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65 ? 14 Epidural volume reduction
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Comparison of Neurological Outcome
Patchels Phase III Trial Patchels Phase III Trial Patchels Phase III Trial Ryus Phase II Trial Ryus Phase II Trial
SRT 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)
Ambulatory rate from nonambulat 62 (10/16) 19 (3/16) Intact rate from deficit 59 (19/27)
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Neurological Outcome by Radiosurgical
Decompression
Neuro before radiosurgery Neuro after RS No
deficit Deficit Normal 31 pts 16
pts Improved - 3 pts Stable - 3
pts Progressed 4 pts 5 pts Total 35 pts 27
pts
81 of total pts improve
19 (12/62) Progress
(Ryu, Cancer 2010)
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Dual grading system of metastatic epidural
compression
Neurological Grade
Radiographic Grade
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
0 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
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Treatment for Canal Compromise at Henry Ford
3 mon
10/08
7/08
Grade 2a, Neuro intact
Renal cell ca, T12, Grade 4b, 18 Gy
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Surgical Options for Spine Metastases

• Ian Lee, MD
• Staff Neurosurgeon
• Hermelin Brain Tumor Center
• Henry Ford Health System
• September 21, 2012
• Comprehensive Spine Symposium

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Disclosures

• None

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Surgery for Spine Metastases

• Up to 35 of cancer patients will develop spine
  metastases
• gt20,000 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

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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

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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)

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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

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Surgery for Spine Metastases

• In 1980s, newer techniques of surgery allowed
  for more aggressive extirpation of disease and
  reconstruction

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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
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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

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Surgery for Spine metastasesRecommendations

• 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 gt 3 months

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Surgery for Spine Metastases

• Surgical Approaches now available
• Posterior
• Laminectomy
• Posterolateral
• Transpedicular
• Costotransversectomy
• Lateral Extracavitary
• Lateral/Anterior
• Retroperitoneal
• Transthoracic

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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. 1998 Jun49(6)609-18
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Anterior/Lateral Approach

• Advantages Directly address pathology
• Disadvantages Requires two-stage operation

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Posterolateral Approaches
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Surgical Approach

• Posterolateral approaches (transpedicular,
  costotransversectomy) have become increasing
  popular
• Allows for circumferential decompression and
  stabilization

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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)

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Surgical technique Transpedicular/Costotransvers
ectomy
From Wang et al. March 2004.J Neurosurg Spine.
2004 Oct1(3)287-98.
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Surgical technique Transpedicular decompression
From Wang et al. March 2004.J Neurosurg Spine.
2004 Oct1(3)287-98.
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Surgical technique - Stabilization
From Wang et al. March 2004.J Neurosurg Spine.
2004 Oct1(3)287-98.
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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

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Surgery for Spine MetastasesCurrent/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

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Spine Metastases - References

• Constans JP, de Divitiis E, Donzelli R, et al
  Spinal metastases with neurological
  manifestations. Review of 600 cases. J Neurosurg
  59111118, 1983
• Sorensen S, Borgesen SE, Rhode K, et al
  Metastatic epidural spinal cord compression.
  Results of treatment and survival. Cancer
  6515021508, 1990
• Byrne TN Spinal cord compression from epidural
  metastases. N Engl J Med 327614619, 1992
• Young RF, Post EM, King GA Treatment of spinal
  epidural metastases. Randomized prospective
  comparison of laminectomy and radiotherapy. J
  Neurosurg 53741748, 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. 2005 Aug
  20-26366(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), 818824, 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)697-708, 2010
• Jacobs WB, Perrin RG. Evaluation and treatment of
  spinal metastases an overview. Neurosurg Focus.
  1511(6)e10, 2001
• Fessler RG, Sturgill. Review complications of
  surgery for thoracic disc disease. M.Surg Neurol.
  1998 Jun49(6)609-18
• 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. 2004
  Oct1(3)287-98.

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

• Reduce pain
• Eradicate or reduce tumor when primary tumors are
  involved
• Prevent neurologic complications
• Treat pathologic fractures and prevent recurrent
  fracture

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Primary and Metastatic Bone DiseaseAvailable
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.
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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 2004232846-853
• Fourney et al J Neurosurg (Spine 1) 2003
  9821-30
• J Clin Neurosci 2011 Jun18(6)763-7. Epub 2011
  Apr 19.
• J Surg Oncol 2010 Jul 1102(1)43-7.
• Radiology 2010254(3)882-890
• AJNR 200728 570-574

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QA

• Jack Rock, M.D.
• Department of Neurosurgery

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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
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Thank you