Spine Conference

1. Spine Conference
Metastatic Squamous Lung Carcinoma to the Spine
UCMC
July 10th , 2015

2. 78 year old woman
cc: T12 metastatic lesion on
CT/PET scan and “legs don’t work”
HPI: visit 6/10/15 ataxia,
numbness, weakness, legs
detached from body, falls
stumbling for 2 weeks, referred
by oncologist. h/o LBP 2 months
with urgent care visit that
prompted lumbar CT 4/24/15,
difficulty walking, Bone scan
5/5/12 T12 lytic lesion CT guided
needle biopsy T12 posterior
elements 5/12/15 revealing
metastatic tumor., PET scan
6/10/15
PMH: RUL lobectomy Aug 2012,
COPD, TIA, B TKA, R RC repair,

3. 2012

4. CT 4/24/15

6. 5/5/15

8. 5/27/15
93% VERSUS 76% ACCURACY LYTIC VERSUS SCLEROTIC

9. PET 6/10/15

14. Youtube pet scan

16. Office visit 6/10/15

17. 6/11/15

22. Lung Ca

27. Intradural v. extradural (90%)
Spinal mets are initial presentation for malignancy in 20% of cases

28. 15% non-contiguous mets

30. 1,638,910/314,000,000=
1 in 192
Md: 31k/5,000k= 1 in 161

31. 3000 total

32. METASTASIS

34. ??????
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36. Oscar Vivien Batson U Penn Prof Anatomy
• Batson OV (1940 Jul). "The function of the vertebral veins and their role in the
spread of metastasis". Annals of Surgery 112 (1): 138–49.

37. Valsalva maneuver
Antonio Maria Valsalva(1666-1723)
Bologna,Italy anatomist
Maneuver expelled pus from the inner ear

38. Most Common Mets
to Bone
(about 70% all metastatic disease eventually involves bone metastasis)
• Breast
• Prostate
• Lung
• Renal
• Hematopoietic tumors
• Thyroid

39. Spinal cord compression: surgery
versus radiation

40. study in the Lancet 2005 revealed spinal cord compression from metastatic disease
ntucky randomized multicenter surgery with radiation v radiation alone
4% v 57%
alking 122 days v 13
walking 62% v 19%

41. Patchell study
• Lancet. 2005 Aug 20-26;366(9486):643-8.
• Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial.
• Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ, Mohiuddin M, Young B.
• Source
• Department of Surgery (Neurosurgery), University of Kentucky Medical Center, Lexington, KY 40536, USA. rpatchell@aol.com
• Abstract
• BACKGROUND:
• The standard treatment for spinal cord compression caused by metastatic cancer is corticosteroids and radiotherapy. The role of
surgery has not been established. We assessed the efficacy of direct decompressive surgery.
• METHODS:
• In this randomised, multi-institutional, non-blinded trial, we randomly assigned patients with spinal cord compression caused by
metastatic cancer to either surgery followed by radiotherapy (n=50) or radiotherapy alone (n=51). Radiotherapy for both treatment
groups was given in ten 3 Gy fractions. The primary endpoint was the ability to walk. Secondary endpoints were urinary continence,
muscle strength and functional status, the need for corticosteroids and opioid analgesics, and survival time. All analyses were by
intention to treat.
• FINDINGS:
• After an interim analysis the study was stopped because the criterion of a predetermined early stopping rule was met. Thus, 123
patients were assessed for eligibility before the study closed and 101 were randomised. Significantly more patients in the surgery
group (42/50, 84%) than in the radiotherapy group (29/51, 57%) were able to walk after treatment (odds ratio 6.2 [95% CI 2.0-19.8]
p=0.001). Patients treated with surgery also retained the ability to walk significantly longer than did those with radiotherapy alone
(median 122 days vs 13 days, p=0.003). 32 patients entered the study unable to walk; significantly more patients in the surgery group
regained the ability to walk than patients in the radiation group (10/16 [62%] vs 3/16 [19%], p=0.01). The need for corticosteroids and
opioid analgesics was significantly reduced in the surgical group.
• INTERPRETATION:
• Direct decompressive surgery plus postoperative radiotherapy is superior to treatment with radiotherapy alone for patients with
spinal cord compression caused by metastatic cancer.

42. Thoracolumbar
junction is a
point of stress

44. 6/19/15 surgery

45. • Youtube video of surgery 6/16/15

51. Spine Conference
July 10, 2015
By: Dr. Seiguer

52. D.S.
8/22/12, S12-5458, right upper lobe biopsy:
Atypical.
8/22/12, C12-442, right bronchial brushings:
Suspicious for malignancy.
8/28/12, U of MD, 01-8-12-10505, right upper
lobectomy and mediastianal lymph nodes: 3.4 cm
squamous cell carcinoma with lymphovascular
invasion. All lymph nodes (2R upper paratracheal,
4R lower paratracheal, 7 subcarinal, R Level 9, R
level 10, and interlobar) all negative.

53. 5/27/15, S15-3211, T12 lesion biopsy:
Metastatic squamous cell carcinoma (CK5/6 and
p63 positive, negative for CK7 and TTF1).
6/19/15, S15-3745, T12-L1 tumor excision:
Metastatic moderately differentiated squamous
cell carcinoma.

54. S15-3211
Biopsy

56. CK5/6

57. p63

59. S15-3745
excision

61. *
*
*

62. * *
*
vessel

67. EXTERNAL BEAM RADIATION
XRT

68. Home POD#1 Pod #4 ileus weakness POD #14 PE L
lower lobe pulmonary artery

69. THANKS!!

74. Stereotactic Radiation
• Axesse
• Cyberknife
• Gamma Knife
• Novalis
• Primatom
• Synergy
• X-Knife
• TomoTherapy
• Trilogy
• Truebeam

77. XRAY ISSUES
Size of lesion
Cortical interruption
Periosteal reaction
Pathologic fracture
Patient age >40 years: likelihood of an isolated
aggressive bony lesion is metastatic is 500
times greater than it being a primary sarcoma
!?

78. Hilton Mirel’s Classification
SCORE Site of lesion Size (cortex) appearance Pain
1 Upper <1/3 blastic Mild
2 Lower 1/3 – 2/3 mixed Moderate
3 Trochanter >2/3 lytic Functional
SCORE RECOMMENDATION
7 and under observe
8 (15% fx) Use judgement
9 and above fix

79. • INTRAMARGINAL
RESECTIONS
LEAVE GROSS
TUMOR BEHIND
• RESECTIONS
WITHIN THE
MARGINAL MARGIN
IN THE REACTIVE
ZONE OF THE
TUMOR LEAVE
MICROSCOPIC
TUMOR BEHIND
• WIDE MARGINS
REMOVE A
NORMAL CUFF OF
TISSUE ALL
AROUND THE
TUMOR BUT MAY
LEAVE BEHIND
SKIP LESIONS IN
THE SAME
COMPARTMENT
• Solitary bone met to remove is thyroid
and renal cell to improve survival

80. Stage Grade Site (1) Metastasis
IA Low Grade T1 - intracompartmental M0 (none)
IB Low Grade T2 - extracompartmental M0 (none)
IIA High Grade T1 - intracompartmental M0 (none)
IIB High Grade T2 - extracompartmental M0 (none)
III Metastatic T1 - intracompartmental M1 (regional or distant)
III Metastatic T2 - extracompartmental M1 (regional or distant)

81. Hypertrophic pulmonary osteoarthropathy

82. Digital clubbing

83. Who should do the investigation
And how?

84. Skeletal met of unknown origin
85% diagnosis prior to biopsy and biopsy gave Dx in 8%
Rougraff BT, Kneisl JS, Simon MA: Skeletal
metastases of unknown origin: A prospective study
of a diagnostic strategy. J Bone Joint Surg Am 1993;
75(9):1276-1281.

85. Reasons for radiographic workup:
1.R/O isolated sarcoma of bone
2.Easier biopsy site
3.Need for preoperative embolization
RENAL CELL
4. avoid biopsy
5.Working diagnosis helps the pathologist
6. H&P, labs, CXR, whole body scan, CT chest/abd/pelvis with oral/iv contrast will identify the primary site in
85% of all cases
Rougraff BT et al. Skeletal metastases of unknown origin. A prospective study of a
diagnostic strategy. JBJS Am. 1993; 75:1276-81

86. Laboratory Tests:
Serum calcium (ionized)
SPEP
PSA
ESF
CRP (noncardiac)
?LFT

95. • 62 female
• Mets L1, T8, L S2
• LUL lesion
• Lesion skull x 2
• Epigastic pain
• L1 lesion at risk for fx
• SPEP/UPEP negative
• Need tissue

101. • Positive: CK7 (cytokeratin) and NAPSIN A
• Negative: CK20 and TTF1 (thyroid transcription factor)

104. 93% VERSUS 76% ACCURACY LYTIC VERSUS SCLEROTIC

106. 1 in 200