metastasis of Spine

1. METASTATIC LESIONS OF SPINE

2. EPIDEMIOLOGY
• METASTATIC TUMOR:- M/C MALIGNANCY OF BONE.
• SPINE:- M/C SITE OF OSSEOUS METASTASES
• 5-10% OF PATIENTS WITH CANCER DEVELOPS SPINE METASTASES.
• ALL AGE GROUPS WITH HIGHEST AGE INCIDENCE BETWEEN 40 TO 65 YEARS.
• M:F :- 3:2

3. LOCATION:-
• THORACIC SPINE (60-80%)
• LUMBAR SPINE (15-30%)
• CERVICAL SPINE (<10%)

4. CLASSIFICATION:-
• BASIS OF ANATOMIC LOCATION:-
1. INTRADURAL:- 5%
1. INTRAMEDULLARY
2. EXTRAMEDULLARY---TERTIARY DROP METS
2. EXTRADURAL:- 95%
1. PURE EPIDURAL:- RARE
2. ARISING FROM VERTEBRAE:- MOST FREQUENT Intramedullary extradural mets
Entrapped in Cauda Equina Syn.
*PerrinRG,LaxtonAW.Metastaticspinedisease: epidemiology,pathophysiology,and evaluation
ofpatients.NeurosurgClinN Am2004;15:365–373

5. PATHOPHYSIOLOGY
• DEPENDS ON :-
1. METASTATIC PROPERTIES OF PRIMARY NEOPLASIA
2. ANATOMIC PROPERTIES OF HOST ORGANISM
3. BIOLOGIC PROPERTIES OF THE SKELETAL HOST

6. BIOLOGY
• POST. HALF OF THE BODY IS FIRST INVOLVED FOLLOWED BY 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.

7. PRESENTATION:-
• PAIN
1. CONSTANT AND LOCALISED
2. RADICULAR
3. AXIAL
• SPINAL DEFORMITY
• NEUROLOGIC DEFICIT
• CONSTITUTIONAL SYMPTOMS
RED FLAG FEATURES:-
Gradual onset, progressive,
constant, night time or
recumbency pain and axial
pain exaberated by
movements in all
directions.

8. DIAGNOSIS
• HISTORY
• PHYSICAL EXAMINATIONS
• LABORATORY STUDIES
• IMAGING STUDIES

9. HISTORY:-
• NATURE OF PATIENTS SYMPTOMS AND THEIR ONSET
• EXPOSURE TO POSSIBLE CARCINOGENS
• FAMILY HISTORY
• REVIEW OF OTHER SYSTEMS

10. PHYSICAL EXAMINATION
• COMPREHENSIVE
• SHOULD PALPATE FOR MASSES DIAGNOSTIC OF A PRIMARY BREAST, THYROID,
PROSTATE, OR RECTAL CARCINOMA

11. LABORATORY STUDIES:-
• COMPLETE BLOOD COUNTS
• SERUM CHEMISTRY
• ESR
• SERUM AND URINE PROTEIN ELECTROPHORESIS
• SERUM TUMOR MARKERS:- PSA, CEA, CA19-9, AFP
• MAMMOGRAPHY
• BONE MARROW BIOPSY

12. IMAGING STUDIES:-
• PLAIN RADIOGRAPHS
• BONE SCAN
• CT SCAN OF CHEST, ABDOMEN, PELVIS AND OF THE SUSPICIOUS AREA
• MRI
• PET SCAN

13. EVALUATION OF PATIENTS WITH KNOWN
PRIMARY:-
History and physical
examination
Radiographs, CXR &lab
test
Suspicion or no
lesion
BONE SCAN

14. BONE SCAN
POLYOSTOTI
C
MONOSTOTIC
IMPENDING FRACTURE NO IMPENING
FRACTURE
CT SCAN/ MRI/ BIOPSY
PERFORM BIOPSY &
STABILIZE
OBSERVE, RADIATE OR
PERFORM BIOPSY

16. EVALUATION OF PATIENT WITH AN
UNKNOWN PRIMARY

18. CHARACTERISATION OF SPINAL LESION
• DIAGNOSTIC IMAGING
• BIOPSY

19. • PLAIN RADIOGRAPHS:-
• LOCATION
• PATTERN OF BONE DESTRUCTION
• VERTEBRAL COLLAPSE
• WINKING OWL SIGN
• DIFFICULT TO DETECT EARLY LESIONS

20. • BONE SCAN
• SUPERIOR SENSITIVITY
• EXTENT OF DISSEMINATION
• DEFINE THE MOST ACCESSIBLE LESION TO BIOPSY IN
CASES OF UNKNOWN PRIMARY

21. COMPUTED TOMOGRAPHY
• IMPROVED SPECIFICITY
• SENSITIVE TO ALTERATION IN
BONE MINERALISATION.
• OSSEOUS DETAILS
• EVALUATION OF CORTICAL PENETRATION.

22. MRI
• SENSITIVITY &SPECIFICITY
• METHOD OF CHOICE TO EVALUATE SPINE
• DEFINE THE INTRAMEDULLARY, INTRADURAL
AND EXTRAMEDULLARY LESIONS
• EXTENT OF LESION
• DIFFERENTIATE FROM OTHER PATHOLOGIES SUCH AS
INFECTION AND OSTEOPOROTIC
• FAT SUPPRESSION AND GADOLINIUM ENHANCEMENT
TO IMPROVE THE DELINEATION

23. PET:-
• USES FLUORINE 18-FLURODEOXYGLUCOSE
• DETECTION OF PRIMARY AND
METASTATIC TUMORS
• RECURRENCES OF TUMOR

24. BIOPSY
TISSUE DIAGNOSIS OF LESION GUIDES THE TREATMENT
• FNAC OR NEEDLE BIOPSY
• CORE BIOPSY
• INCISIONAL BIOPSY
• EXCISIONAL BIOPSY

25. PERCUTANEOUS APPROACHES FOR BIOPSY
POSTEROCERVICAL C1-C3 TRANSORAL
SUB AXIAL CERVICAL ANT OR POST STERNOCLEIDOMASTOID
THORACIC AND LUMBAR TRANSPEDICULAR OR POSTEROLATERAL
SACRAL POSTEROLATERAL

26. TREATMENT
• DIRECTED TO PRIMARY

27. LUNG CANCER
• METASTATIC STAGE IV
• BAD PROGNOSIS
• MEDIAN SURVIVAL IS <6MONTHS
• SMALL CELL LC
• CT
• RT
• NON SMALL CELL LC
• COMBINED CT RT
• RESECTION OF TUMORS WITH VERTEBRECTOMY.

28. PROSTATE CANCER
• HORMONE WITHDRAWAL:-
• BILATERAL ORCHIDECTOMIES OR ANDROGEN DEPRIVATION
• RADIATION THERAPY
• CHEMOTHERAPY
• SURGERY
• AVERAGE SURVIVAL AROUND 12 MONTHS

29. BREAST CANCER
• METASTATIC CANCER- MEDIAN SURVIVAL 3 YEARS
• CT
• HRT:- TAMOXIFEN
• BISPHOSPHONATES

30. THYROID CANCER
• THYROIDECTOMY FOLLOWED BY IODINE-131 AT THERAPEUTIC DOSES
• PALLIATIVE RADIOTHERAPY
• OVERALL 10 YEAR SURVIVAL RATE—35%

31. RENAL CELL CARCINOMA
Metastatic :- median
survival 6 to 9 months
Combined
chemo/immune therapy
Radiotherapy
Preoperative
embolization and
surgery

32. TREATMENT
• DIRECTED TO SPINAL LESION

33. HISTORICAL ASPECTS
• EARLY 1990’S :- SURGICAL TREATMENT SUCH AS DECOMPRESSIVE LAMINECTOMY
• 1953:- 1ST PATIENT WAS TREATED WITH LINEAR ACCELERATOR
• 1980’S ADVENT OF SPINAL IMPLANTS
• RECENT :- INTENSITY-MODULATED RADIATION THERAPY (IMRT), STEREOTACTIC
RADIOSURGERY AND STEREOTACTIC RADIOTHERPY

34. APPROACH:-
• LIFE EXPECTANCY
• BIOPSY:- HISTOLOGY TO PREDICT THE RESPONSE TO NON OPERATIVE
MANAGEMENT
• STABILITY
• CLINICAL PRESENTATION:- PAIN AND NEUROLOGICAL STATUS

35. PATIENTS PRESENTING WITH BACKPAIN AND
NO NEUROLOGICAL DEFICIT.
• ANALGESICS
• PHYSIOTHERAPY AND BRACING
• BISPHOSPHONATES
• VERTEBROPLASTY OR KYPHOPLASTY
• RFA
• RT
• SURGICAL STABILIZATION IN PATIENTS WITH LIFE EXPECTANCY OF >3MONTHS.

36. ANALGESIC TREATMENT
• THREE STEP MODEL OF ANALGESIA
• NSAIDS
• SHORT ACTING OPIOIDS
• PURE OPIOID AGONISTS
• DISEASE – MODIFYING THERAPIES, COANALGESIC/ ADJUVANT ADMINISTRATION
AND INTERVENTIONA; STRATEGIES

37. BISPHOSPHONATES
• TREAT HYPERCALCEMIA
• POTENT INHIBITORS OF NORMAL AND PATHOLOGICAL BONE RESORPTION.
• ANTIANGIOGENIC EFFECTS AND ANTITUMORAL ACTIVITY
PHYSICAL THERAPY AND BRACING
• ORTHOSES
• BRACING

39. CORTICOSTEROIDS
• SHOULD BE PRESCRIBED IN ALL PATIENTS PRESENTING WITH NEUROLOGICAL
DEFICIT.
• HIGH DOSE DEXAMETHASONE STANDARD DOSE
• METHYL PREDNISOLONE

40. RADIATION THERAPY

41. 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

42. 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

43. SYSTEMIC RADIOISOTOPE THERAPY
• STRONTIUM – 89, SAMARIUM - 153 AND RHENIUM – 186
• AFFINITY TO OSTEOBLASTIC BONE
• LOCAL ANTITUMOUR ACTIVITY AND ANALGESIC AFFECT

44. VERTEBROPLASTY
• 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

45. MECHANISM OF PAIN RELIEF:-
• STABILIZATION OF MICROFRACTURES
• REDUCTION OF MECHANICAL FORCES
• DESTRUCTION OF THE NERVE TERMINALS BY THE CYTOTOXICITY OF PMMA

46. KYPHOPLASTY
• PERCUTANEOUS INTRODUCTION OF A KYPHX BALLOON
• INFLATED TO REDUCE THE FRACTURE AND DEFLATION
• VOID FILLED WITH PMMA

47. ADVANTAGES

48. RADIOFREQUENCY ABLATION
• USES THERMAL ENERGY TO DESTROY THE TUMOUR CELLS
• COMBINED TREATMENT WITH VERTEBROPLASTY

49. Radiofrequency Ablation Probe at T9
Anterior-posterior and lateral
fluoroscopic images of the
radiofrequency ablation probe in the T9

50. SURGICAL TREATMENT
• 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

51. EMBOLIZATION
• PRE OPERATIVE FOR VASCULAR METASTATIC
LESIONS SUCH AS RENAL CELL, THYROID
CARCINOMA, SQUAMOUS AND
ADENOCARCINOMAS OF LUNG

52. OPEN SURGERY
• RESECTION
• DECOMPRESSION
• RECONSTRUCTION AND STABILIZATION

53. INDICATIONS

55. 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.

58. 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

59. SURGICAL STAGING
TOMITA CLASSIFICATION- BUILT ON ENNEKING ONCOLOGICAL SYSTEM
• DESCRIPTION OF THE AFFECTED SITE
• METASTATIC EXTENT
• INTRACOMPARTMENTAL(1-3)
• EXTRACOMPARTMENTAL(4-7)

60. SURGICAL TREATMENT BASED ON STAGING
AND LIFE EXPECTANCY

61. SURGICAL APPROACH
• LOCATION OF THE TUMOUR
• SPINAL INSTABILITY
• NEUROLOGICAL STATUS

62. JAMES WEINSTEIN MODEL
Zones IB to IVB – Extraosseous extensions of the tumour
beyond cortical bone
Zones IC to IVC - Associated regional or distant metastases

63. • ZONES I AND II LESIONS - POSTERIOR OR
POSTEROLATERAL SURGICAL APPROACH
• ZONE III LESIONS – ANTERIOR SURGICAL APPROACH
• ZONE IV LESIONS - COMBINED ANTERIOR AND
POSTERIOR APPROACH

64. SURGICAL APPROACHES

65. RECONSTRUCTION AND STABILIZATION
• ANTERIOR
• POSTERIOR
SUBCLASSIFIED ACCORDING TO THE LEVEL

66. 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

67. • 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

68. INSTRUMENTATION
• FIXATION USING RODS AND SCREWS
• VERTEBRAL BODY RECONSTRUCTION--- METAL CAGE, CEMENT, CERAMIC
SPACER OR GRAFTS (AUTOLOGOUS OR ALLOGRAFT)

69. 57 YEAR OLD FEMALE OF LUNG CARCINOMA WITH
METASTASES D5 UNDERWENT CIRCUMFERENTIAL TUMOR
RESECTION AND SIMULTANEOUS ANTERIOR AND
POSTERIOR RECONSTRUCTION BY COMBINED APPROACH.

70. 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

71. LUMBOSACRAL JUNCTION AND SACRUM
• RESECTION AND RECONSTRUCTION BY PEDICLE SCREWS AND
RODS BY MODIFIED GALVESTON TECHNIQUE

72. SUMMARY
• MULTIDISCIPLINARY APPROACH
• SURGERY VS RADIOTHERAPY
• MANAGEMENT OFTEN NOT CLEAR CUT
• CURE IS NOT GOAL

73. REFERENCES
• 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
• G S KULKARNI PG NO 696-710