Metastases of spine

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Metastases of spine

  1. 1. METASTATIC LESIONS OF SPINE Dr. Sushil Paudel
  2. 2.  Metastatic tumour - most common malignancy of bone  Spine - most common site of osseous metastases  5-10% of the patients with cancer develop spine metastases*  All age groups with highest age incidence in between 40 and 65 years  Male:Female – 3:2 *Ries LAG, Melbert D, Krapcho M, et al, eds. SEER Cancer Statistics Review,1975–2005. National Cancer Institute. Bethes
  3. 3.  LOCATION ◦ Thoracic spine (60-80%) ◦ Lumbar spine (15-30%) ◦ Cervical spine (<10%)
  4. 4.  PRIMARY* ◦ Unknown(33%) ◦ Breast (21%) ◦ Lung (14%) ◦ Prostate(8%) ◦ Gastrointestinal (5%) ◦ Thyroid (3%) *Ries LAG, Melbert D, Krapcho M, et al, eds. SEER Cancer Statistics Review,1975–2005. National Cancer Institute. Bethesda
  5. 5. Basis of anatomic location*  Intradural - 5% ◦ Intramedullary ◦ Extramedullary – tertiary drop metastases  Extradural - 95% ◦ Pure epidural – rare ◦ Arising from the vertebrae - most frequent *Perrin RG, Laxton AW. Metastatic spine disease: epidemiology, pathophysiology, and evaluation of patients. Neurosurg Clin N Am 2004;15:365–373 Intramedullary extradural metastases entrapped in cauda equina
  6. 6.  Metastatic properties of primary neoplasia  Anatomic properties of the host organism  Biologic properties of the skeletal host
  7. 7.  Posterior half of the body is seeded first, anterior half, pedicles and lateral masses are involved later  Local spread to adjacent vertebra  Spread to epidural space  Induce osteoblastic or lytic lesions, diffuse osteopenia or variable combination  Replacement of marrow tissue with neoplasm, progressive collapse and finally spinal instability
  8. 8.  Pain – 85% ◦ Constant and localised ◦ Radicular ◦ Axial  Spinal deformity  Neurologic deficit  Constitutional symptoms RED FLAG features – Gradual onset, progressive, constant, night time or recumbency pain and axial pain exaberated by movement in all directions
  9. 9.  History  Physical examination  Laboratory studies  Imaging studies
  10. 10.  HISTORY ◦ Nature of patient’s symptoms and their onset ◦ Exposure to possible carcinogens ◦ Family history ◦ Review of other systems
  11. 11.  PHYSICAL EXAMINATION ◦ Comprehensive ◦ Should palpate for masses diagnostic of a primary breast, thyroid, prostate, or rectal carcinoma
  12. 12.  LABORATORY STUDIES ◦ Complete blood counts ◦ Serum chemistry ◦ ESR ◦ Serum and urine protein electrophoresis ◦ Serum tumour markers- PSA, CEA, CA 19-9, AFP ◦ Mammography ◦ Bone marrow biopsy
  13. 13. IMAGING STUDIES  Plain radiographs  Bone scan  CT scan of chest, abdomen, pelvis and of the suspicious area  MRI  PET scan
  14. 14. History and physical examination Local plain films, chest radiographs and Laboratory tests Suspicious or no lesion Bone scan
  15. 15. Bone scan Polyostotic Monostotic CT scan/MR imaging Perform biopsyImpending fracture No impending fracture Perform biopsy and stabilise Observe, radiate or perform biopsy
  16. 16. Biopsy Primary sarcoma Metastatic carcinoma Refer to sarcoma surgeon Renal or thyroid primary Non Renal or thyroid primary Treat as indicated
  17. 17. History and physical examination Chest radiographs and Laboratory tests Myeloma Primary not identified Primary identified Stage and as indicated Bone scan, CT scan of chest, abdomen and pelvis Skeletal survey; Refer to medical oncologist
  18. 18. Bone scan; CT scan of chest, abdomen and pelvis Primary identified Solitary lesion and primary not identified Multiple bone lesions and Primary n0t identified Assume sarcoma; Refer to orthopaedic oncologist Perform biopsy on most appropriate site Stage and treat as indicated
  19. 19.  Diagnostic imaging  Biopsy
  20. 20.  PLAIN RADIOGRAPHS ◦ Location ◦ Pattern of bone destruction ◦ Vertebral collapse ◦ Winking owl sign ◦ Difficult to detect early lesions
  21. 21.  BONE SCAN ◦ Superior sensitivity ◦ Extent of dissemination ◦ Define the most accessible lesion to biopsy in cases of unknown primary  SPECT
  22. 22.  COMPUTED TOMOGRAPHY ◦ Improved specificity ◦ Sensitive to alterations in bone mineralisation ◦ Osseous details ◦ Evaluation of cortical penetration
  23. 23.  MAGNETIC RESONANCE IMAGING ◦ Superior sensitivity and specificity ◦ Method of choice to evaluate spine ◦ Define the intramedullary, intradural and extramedullary lesions ◦ Extent of the lesion ◦ Differentiation from other pathologies such as infection and osteoporotic ◦ Fat suppression and Gadolinium enhancement to improve the delineation
  24. 24.  POSITRON EMISSION TOMOGRAPHY ◦ Uses Flourine-18-Flouro deoxy glucose ◦ MRgIc calculation by Patlak analysis in ROI ◦ Detection of primary and metastatic tumours ◦ Recurrences of tumour ◦ Differentiation of osteoporotic VCF from pathologic VCF’s
  25. 25. Tissue diagnosis of lesion guides the treatment  FNAC or needle biopsy  Core biopsy  Incisional biopsy  Excisional biopsy
  26. 26.  PER CUTANEOUS APPROACHES FOR BIOPSY Posterior cervical C 1 – 3= Transoral Sub axial cervical Anterior or posterior to sternocleidomastoid Thoracic and Lumbar Transpedicular or Postero lateral Sacral Posterolateral
  27. 27. DIRECTED TO PRIMARY
  28. 28. LUNG CANCER  Metastatic stage IV – dismal prognosis, median survival < 6 months ◦ Small cell LC  Chemotherapy  Radiotherpy ◦ Non small cell LC  Combined chemo and radiotherapy  Resection of the tumour with vertebrectomy
  29. 29. PROSTATE CANCER  Hormone withdrawal – bilateral orchidectomies or androgen deprivation (LHRH agonists, flutamide etc)  Radiation therapy  Chemotherapy  Surgery  Average survival around 12 months
  30. 30. BREAST CANCER  Metastatic cancer – median survival 3 years  Chemotherapy  Hormonal therapy – Tamoxifen  Bisphosphonates
  31. 31. THYROID CANCER  Thyroidectomy followed by iodine – 131 at therapeutic doses  Palliative radiotherapy  Overall 10 year survival rate – 35%
  32. 32. RENAL CELL CARCINOMA  Metastatic – median survival 6 to 9 months  Combined chemo/immune therapy  Radiotherapy  Pre operative Embolisation and Surgery
  33. 33. DIRECTED TO SPINAL LESION
  34. 34.  Early 1900’ s – surgical treatment such as decompressive laminectomy  1953 - first patient was treated with a linear accelerator  1980’ s – advent of spinal implants  Recent developments - Intensity-modulated radiation therapy (IMRT), stereotactic radiosurgery, and stereotactic radiotherapy
  35. 35.  Life expectancy  Biopsy – Histology to predict the response to non operative management  Stability  Clinical presentation – Pain and Neurological status
  36. 36.  Analgesic treatment  Physical therapy and bracing  Bisphosphonates  Vertebroplasty or Kyphoplasty  Radiofrequency ablation  Radiation therapy  Surgical stabilization in patients with life expectancy of more than 3 months PATIENTS PRESENTING WITH PAIN AND NO NEUROLOGICAL DEFICIT
  37. 37. ANALGESIC TREATMENT  Three Step model of analgesia ◦ NSAIDS ◦ Short acting opioids ◦ Pure opioid agonists  Disease-modifying therapies, coanalgesic/adjuvant administration, and interventional strategies (cognitive, behavioral, physiatric etc)
  38. 38. BISPHOSPHONATES  Treat hypercalcemia  Potent inhibitors of normal and pathological bone resorption.  Antiangiogenic effects and Antitumoral activity* PHYSICAL THERAPY AND BRACING  Orthoses  Bracing *Diel IJ, Solomayer EF, Costa SD, et al: Reduction in new metastases in breast cancer with adjuvant clodronate treatment. N Engl J Med 339:357–363, 1998
  39. 39. Emergency whole spine MRI Dexamethasone Radiosensitivity+ - Unstable spine Vertebroplasty Or Kyphoplasty Radiotherapy Neurological deficit<24 hrs Surgical candidate _ + - Surgical decompression and stabilization followed by radiotherapy +
  40. 40. CORTICOSTEROIDS  Should be prescribed in all patients presenting with neurological deficit ◦ High dose dexamethasone ◦ Standard dose ◦ Methyl prednisolone
  41. 41. General indications
  42. 42.  EXTERNAL BEAM RADIOTHERAPY ◦ Pain-Single fraction radiotherapy ◦ Neurological deficit-short course and long course regimens  Intra operative brachytherapy  Cobalt-60 teletherapy  Injectable radioisotopes  Megavoltage therapy  Proton/neutron/electron bombardment
  43. 43.  IMRT, STEREOTACTIC RADIOSURGERY AND STEREO TACTIC RADIOTHERAPY* ◦ Deliver high doses safely ◦ Possible to irradiate spine without affecting spinal cord *De Salles AA, Pedroso AG, Medin P, Agazaryan N, Solberg T, Cabatan-Awang C, et al: Spinal lesions treated with Novalis shaped beam intensity-modulated radiosurgery and stereotactic radiotherapy. J Neurosurg 101 (3 Suppl):435–440, 2004
  44. 44. (A) Target planning image. The thick dark pink line surrounds the target volume. The thick dark green line represents the thecal sac (main organ at risk). The remaining lines represent isodose lines. (B) Dose-volume histograms demonstrating steep falloff of radiation, with high doses being applied to the lesion and a low volume of the thecal sac being exposed to significant dose.
  45. 45.  SYSTEMIC RADIOISOTOPE THERAPY ◦ Strontium – 89, Samarium - 153 and Rhenium – 186 ◦ Affinity to osteoblastic bone ◦ Local antitumour activity and analgesic affect* *Serafini AN: Systemic metabolic radiotherapy with samarium-15 EDTMP for the treatment of painful bone metastasis. Q J Nucl Med 45:91–99, 2001
  46. 46.  Injection of PMMA into the involved vertebral body under fluoroscopic guidance.  Reinforcement of the bone and stabilization of anterior column relieves pain  PMMA – Anti tumour activity
  47. 47.  MECHANISM OF PAIN RELIEF* ◦ Stabilization of microfractures ◦ Reduction of mechanical forces ◦ Destruction of the nerve terminals by the cytotoxicity of PMMA *Cotten A, Dewatre F, Cortet B, et al. Percutaneous vertebroplasty for osteolytic metastases and myeloma: effects of the percentage of lesion filling and the leakage of methyl methacrylate at clinical follow-up. Radiology 1996;200:525–530
  48. 48.  Percutaneous introduction of a KyphX balloon  Inflated to reduce the fracture and deflation  Void filled with PMMA
  49. 49. Low extravasation rate Pain relief equivalent to that of vertebroplasty Can restore the lost vertebral height Can correct the sagital balance Can use more viscous cement Increases the vertebral body strength Increases the vertebral body stability Can provide tissue for diagnosis ADVANTAGES
  50. 50.  Uses thermal energy to destroy the tumour cells  Combined treatment with vertebroplasty* *Schaefer O, Lohrmann C, Markmiller M, Uhrmeister P, Langer M. Technical innovation: combined treatment of a spinal metastasis with radiofrequency heat ablation and vertebroplasty. Am J Roent 2003;180:1075–1077
  51. 51. Radiofrequency Ablation Probe at T9 Anterior-posterior (a) and lateral (b) fluoroscopic images of the radiofrequency ablation probe in the T9 vertebral body
  52. 52.  Radiofrequency ablation combined with vertebroplasty/kyphoplasty  Tumour debulking combined with VB augmentation ◦ Ablation using LITT (laser induced thermotherapy) before cement placement * *Ahn H, Mousavi P, Chin L, et al. The effect of pre- vertebroplasty tumor ablation using laser-induced thermotherapy on biomechanical stability and cement fill in the metastatic spine. Eur Spine J 2007;16:1171–78. Epub 2007 Apr 20
  53. 53. A 71-year-old woman with undifferentiated cancer and a lesion at L4. B and C, A void is created in the vertebral body by debulking the spinal tumor using the plasma radio-frequency– based wand before vertebral body augmentation with bone cement. D–F, Axial (D and E) and sagittal (F) views by using MR imaging show excellent anterior placement
  54. 54.  Vertebral body augmentation combined with hardware* ◦ Short segment pedicle screw fixation combined with vertebroplasty/kyphoplasty in lieu of traditional long segment fusion *Cho DY, Lee WY, Sheu PC. Treatment of thoracolumbar burst fractures with polymethyl methacrylate vertebroplasty and short- segment pedicle screw fixation.Neurosurgery 2003;53:1354–60, discussion 1360-61
  55. 55.  GOALS ◦ Obtaining tissue in case of an unknown diagnosis ◦ Relief of neurologic symptoms by decompression ◦ Relief of pain by stabilization and reconstruction of the spinal column
  56. 56.  Pre operative for vascular metastatic lesions such as renal cell, thyroid carcinoma, squamous and adenocarcinomas of lung
  57. 57.  Resection  Decompression  Reconstruction and stabilization
  58. 58. Radiation- and chemotherapy-resistant tumors (e.g., squamous and renal cell) Acute or progressive spinal cord compression Recurrent tumor in patients who have already received maximal doses of chemotherapy/radiation Pain associated with collapse in vertebral height of greater than 50%, a 50% kyphotic deformity, or more than 70% of the vertebral body destroyed Isolated metastases in which durable remissions can potentially be achieved (e.g., renal, breast, thyroid) Impending fracture
  59. 59. SCORING SYSTEMS  Karnofsky score estimates a patient's ability to carry out normal activities, work, and care for themselves.  The Tokuhashi index ◦ Karnofsky index ◦ Neurologic status ◦ Metastatic disease ◦ Cancer type ◦ Surgical resectability.
  60. 60. Total Tokuhashi score Life expectancy    0–4    <3 mo    5–8    <6 mo    9–12    >6 mo Tokuhashi score is developed as an assessment tool to select the most suitable surgical procedure with respect to predicted prognosis
  61. 61. Tomita classification- built on Enneking oncological system  Description of the affected site  Metastatic extent ◦ Intracompartmental(1-3) ◦ Extracompartmental(4-7) 1. Vertebral body 2. One or both pedicles 3. Lamina and spinous process 4. Epidural canal 5. Paravertebral area 6. Adjacent vertebra 7. Skip lesions
  62. 62. Tokuhashi score Life expectancy Tomita classification Surgical procedure (all receive radiation) 0–4 <3 mo 1–7 Laminectomy and stabilization 5–8 3–6 mo 1–7 Posterior decompression, stabilization, and  reconstruction 9–12 >6 mo 1–3 En bloc with vertebrectomy and 360-degree  reconstruction 4–6 Intralesional vertebrectomy and 360-degree  reconstruction 7 Posterior decompression and stabilization
  63. 63.  Location of the tumour  Spinal instability  Neurological status
  64. 64. James weinstein model Zones IB to IVB – Extraosseous extensions of the tumour beyond cortical bone Zones IC to IVC - Associated regional or distant metastases
  65. 65. • Zones I and II lesions - posterior or posterolateral surgical approach  Zone III lesions – anterior surgical approach  Zone IV lesions - combined anterior and posterior approach
  66. 66.  SURGICAL APPROACHES LEVEL ANTERIOR POSTERIOR Upper cervical Transoral, Extraoral, Extreme lateral Midline Lower cervical Southwick Robinson Midline Cervicothoracic Sternal splitting, Low costotransversectomy Midline Costotransversectomy Thoracic Thoracotomy Costotranversectomy Costotransversectomy Transpedicular Thoracolumbar 11th rib extrapleural retroperitoneal Midline Posterolateral Lumbar Retroperitoneal Transabdominal Midline,Transpedicular Posterolateral
  67. 67.  RECONSTRUCTION AND STABILIZATION ◦ Anterior ◦ Posterior Subclassified according to the level
  68. 68. THORACIC SPINE  Disease involving vertebral body at 1 or 2 levels- Transthoracic vertebrectomy and anterior reconstruction  Single stage posterolateral decompression and stabilisation – patients with specific contraindication to thoracotomy  Significant kyphosis with VB collapse, disease involving DL junction – posterior stabilization with anterior reconstruction
  69. 69.  Inclusion of significant portion of chest wall in tumour resection – posterior stabilization to prevent the risk of kyphoscoliosis  Cases of tumours involving VB posterior elements and chest wall – combined approach for resection and VB reconstruction, anterior and posterior stabilization
  70. 70. INSTRUMENTATION  Fixation using rods and screws  Vertebral body reconstruction – metal cage, cement, ceramic spacer, or grafts( autologous or allograft)
  71. 71. 57 year old female of lung carcinoma with metastases D5 underwent circumferential tumor resection and simultaneous anterior and posterior reconstruction by combined approach.
  72. 72. LUMBAR SPINE  Standard retroperitoneal approach – excellent exposure  Single level L1-3 disease – vertebrectomy and anterior reconstruction  Disease limited to L5 – posterolateral decompression and stabilisation  Multilevel disease – palliative posterolateral decompression
  73. 73. LUMBOSACRAL JUNCTION AND SACRUM  Resection and reconstruction by pedicle screws and rods by modified Galveston technique
  74. 74.  Cure is not the goal  Multidisciplinary approach  Surgery vs Radiotherapy*  Management often not clear cut 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;366:643-8.
  75. 75.  Adult and Pediatric spine, 3rd edition  Spinal Extradural metastases; Review of current treatment options.CA Cancer J Clin 2008;58;245- 259  Spinal instability and deformity due to neoplastic conditions.Neurosurg Focus 14 (1):Article 8, 2003  Bone metastases.Tumors

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