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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
- 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
- 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