Approach To Spinal Metastasis

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Approach To Spinal Metastasis

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Approach To Spinal Metastasis

  1. 1. Approach to Spinal Metastasis by Nawaz Hussain b Mohd Amir Spine Unit Dept. of Orthopaedics HUSM 8th August 2006
  2. 2. Introduction  Bone is a common site for carcinoma metastasis  Approximately 70% of pts with cancer have evidence of metastasis at the time of their death  Spinal Column is the most common location for osseous sites for metastatic deposits  Up to 40% of pts with cancer has spinal column involvement.
  3. 3. Introduction  Not all spinal metastasis lead to neurologic disorder  Spinal cord compression from epidural metastasis occurs in 5-10 % of cancer pts  10-20% of this will be symptomatic (25 000 pts a year in US –Klimo and Schmidt-2004)
  4. 4.  Metastatic spine disease can involve one of 3 locations - Vertebral column – 85% - post. half - Paravertebral region – 10-15% - Epidural/subarachnoid/intramedullary space - < 5%
  5. 5.  Intradural metastasis – extremely rare but there are reported cases  Multiple level at noncontiguous levels – 10-40%
  6. 6. Primary site Coleman - 1994  Breast – 73%  Prostate -68% 80%  Lung-36%  Thyroid , kidney , GIT ,endometrium, cervix,bladder -< 20% - Klimo and schimdt -2004 - Prostate ,breast, melanoma, lung – 90.5%,74.3%,54.5%,44.9%
  7. 7. Primary site  Frequency of neurologic deficit secondary to epidural spinal cord compression varies with the site of primary disease - Breast – 22% - Lung - 15% - Prostate -10% Some pts present with neurologic dysfunction and spinal pain without knowing primary site – in old literature frequency is up to 70% and 50% of them found to be from lung
  8. 8. Approach  History i. General / conventional symptoms - bony pain , back pain ,numbness , weakness – bladder / bowel control - LOA , LOW ii Specific history -Breast – past history ,lumps ,pain, similiar family hx -prostate – past hx , urinary Sx -lung - past hx , smoking,cough,hemoptysis - thyroid – past hx, swelling , hyperthyroidism
  9. 9.  Physical Examination. ii. General – general condition - cachexia, anemia , hydration, nutritional vi. Potential primary site – - breast , prostate, lung ,thyroid , abdomen ,etc - lymph nodes
  10. 10. Approach…..  P/E…… iii. Full neurological examination motor , sensory…etc.
  11. 11. Investigation  1 . Blood - Anemia - thrombocytopenia - Increase LDH / u.acid / cal. /ALP/ Acid Phophotase(prostate)/ TFT -Serum markers – CEA , Ca 125 , PSA
  12. 12. Ix  Imaging  Plain x-ray - Bone mets can be purely lytic, blastic ,mixed i. Most metastasis are predominantly lytic - lung,kidney,breast,GIT,melanoma ii Blastic – prostate , bronch. carcinoids,bladder,stomach iii. Mixed – breast ,lung,GIT
  13. 13. Plain X-ray - In cancellous bone lytic lesion remain occult until it completely destroys trabaculae and reach 2-3 cm in diameter. Needs 30 – 50 % of destruction. - In cortical bone – small lytic lesion can de detected earlier
  14. 14.  Plain x-ray Depends on whether the primary is known or not I . Primary is known Asymptomatic – not for skeletal survey - bone scan is method of choice - if bone scan positive confine x-ray to site of localisation Symptomatic - Localised x-ray , skeletal survey
  15. 15.  ii. Primary is unknown - usually has local symptoms - local x-ray , skeletal survey  During follow ups , course of tumour therapy
  16. 16. Ix Imaging Bone Scan - Most sensitive diagnostic tool - But it gives multiple levels of involvement without clarifying the level - All cancer pts regardless primary known ,unknown - Follow ups
  17. 17.  Ct scan -Allows visualization of i. even small areas of vertebral destruction ii. Assessment of extent of paravertebral soft tissue masses iii. Extent and direction of impingement of spinal cord by bone debris / tumour - Limitation – failure to identify second site of mets. - 10% of pts
  18. 18.  MRI Superior in evaluating iii. soft tissue mass iv. Neural elements v. Multiple level of vertebral involvement Findings – Hypointense T1 , hyperintense in T2 and gadolinium enhanced T1
  19. 19.  Biopsy - Most literature suggest some type e.g ct guided biopsyof biopsy in order to specify correctly the type of malignancy - Even in known primary - However , here the problem of consent limits the use of this method in establishing diagnosis due to its invasiveness .
  20. 20. Management  General Mx  Medical Mx / Radiotherapy Mx  Surgical Mx  Pain Mx
  21. 21.  General Mx. - Anemia - Nutritional Status - Hydrational status - Supplements
  22. 22.  Medical Mx i.Chemotherapy ii.Hormonal iii Biphosphonate
  23. 23.  Chemotherapy Given as therapeutic and palliative treatment especially in Breast , lung , Renal cell ca. , prostate(less) Needs multi disciplinary approach
  24. 24.  Hormonal - Breast , prostate and endometrial ca. - Endocrine dependant organs. - Regulate and manipulate regulatory hormones as anti -tumour therapy
  25. 25.  Biphosphonate - Inhibit osteoclast-mediated resorption - Induce osteoclast apoptosis - Standard treatment in hypercalcemia in malignancy - Reduces metastatic bone pain esp. clodronate and pamidronate ( Ernst et al-1992 , Coleman et al -1996) - Recalcification
  26. 26.  Radiotherapy - Pain relief – mode of action not really understood – reduces tumour bulk, reduces pain mediator (PG)releasing cells - Post fixation irradiation - Prevention of spinal cord compression- recent vertebral collapse - Pts with contraindication for surgery
  27. 27. Surgical Mx  Mostly Palliative Indications iii. Intractable pain unresponsive to non operative measures iv. Obvious spinal instability v. Clinically significant neural compression from retropulsed bone or spinal instability vi. Radioresistant tumours
  28. 28. Depends on iii. Pts tolerability to surgery e.g general medical condition iv. Estimated life expectancy
  29. 29.  Goals of Surgery ii. Correct and prevent deformity by stabilizing deformity iii. Decompressing neural structures iv. Open biopsy if primary unknown
  30. 30.  Pre-operative prognostic values/scoring Score = < 5 dies within 3 months > 9 survives average 12 mths Surgery = <5 non surgical , > 9 surgical
  31. 31. Category iii – grey area , either medical or surgical . - if there is severe epidural cord compression non radiosensistive , needs surgery
  32. 32. Score 2-3 – wide / marginal for long term survival 4-5 – marginal/intralesional 6-7 – palliative surgery for short term palliation 8-10 – non operative supportive care
  33. 33. Surgical approach  Anterior approach - modern era - Predominant area of metastasis - Does not disturb posterior stability in presence of the kyphosis - Pain relief in 80 – 95% of pts - Neurologic improvement in 75% of pts
  34. 34. Surgical approach……  Post decompressive laminectomy - old era - limited value in regaining neurologic function - Laminectomy + radiotx no more effective than radiotx alone.
  35. 35.  Anterior –posterior approach - High grade instability - Ant and posterior compression - Contiguous vertebral involvement - Need for en-bloc resection of tumour
  36. 36.  Other approches -costotransversectomy – thoracic region -pt unable to tolerate thoracotomy -Postolateral approach – cervical / lumbar region
  37. 37.  VERTEBROPLASTY ( deramound 1990) - Good stabilisation and analgesia to the diseased vertebra. - But must have intact cortex - Used if contraindicated for surgery eg post irradiated patient
  38. 38. Conclusion  Spine is the most frequent location for skeletal metastasis  Mode of treatment and can be chosen by using the many scoring systems(Tokuhashi , Harrington , Tomita etc) but it must be tailored according to each patient  Advances in imaging and instrumentation allowed improvements in the techniques of excision of tumour and stabilisation.  Surgical decision making is a complex issue but the treatment of spinal mets. remains largely palliative.

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