This document discusses spinal metastases. Key points include: - Vertebral metastases are the first sign of malignancy in 12-20% of cases and commonly occur in the thoracolumbar region. - Symptoms include spinal pain and neurologic deficit due to destruction of vertebral elements, instability, or compression/infiltration of spinal cord/nerves. - Diagnosis involves imaging like MRI, CT, PET, or biopsy. - Treatment includes medical options like chemotherapy, radiation, steroids, or bisphosphonates as well as surgical options depending on factors like instability, pain level, tumor type, and life expectancy. - Scoring systems help evaluate patients for surgical vs palliative

2. EPIDEMIOLOGY

3. METASTASIS
CA- breast 45-85%
CA- lung 35-60%
CA-kidney 35-40%
CA- prostate 35-85%
CA- thyroid

4. The most common location for
skeletal metastasis:
Thoracolumbar region ~ 70%
Lumbar and sacral spine ~ 20%
Cervical spine ~ 10%

6. Vertebral metastases are the first sign of
malignant disease in 12% to 20% of the
cases.

7. Clinical symptoms of spinal
metastasis;
Pain
Neurologic deficit

8. The spinal pain may be due:
In destruction of the anatomic
vertebral elements as a result of
metastases
Resulting spinal instability
The pain is possible to occur as a
result of:
Compression or
infiltration of the spinal cord – nerves
from neoplasmatic masses.

9. Pathologic spinal fracture
Instability
Compression
of the neural
tissues
Neurologic
deficit
Spinal pain

10. Diagnosis of spinal metastases

12. M.R.I. Kidney’s metastasis

13. SCANNING Tc 99 MDP

14. P.E.T.

15. Biopsy of the spine
•C.T. – guided percutaneous
needle - trocar
•Graig’s trocar

16. BREAST ADENOCARCINOMA : SPINAL METASTASIS

17. TREATMENT
Medical treatment
•Chemotherapy
•Hormone therapy
•Immunotherapy
Radiotherapy
Operative

18. Chemotherapy
•Anti-tumor medication
•Steroids
•Bi-phosphonates
MEDICAL TREATMENT

19. CHEMOTHERAPY
Highly sensitive
Childhood cancers like
•Acute lymphocytic leukemia
•Wilms tumor
•Ewing’s tumor
•Retinoblastoma
•Rhabdomyosarcoma
Hodgkin’s lymphoma.
Carcinoma of the testis.
Choriocarcinoma.
Burkitts tumor.
Acute promyelocytic leukemia.

20. Moderately sensitive
•Adenocarcinoma of breast.
•Non-Hodgkin’s lymphoma.
•Lung cancer.
•Osteosarcoma.
•Adult myeloid and lymphocytic leukemia.
•Carcinoma of the prostate.
•Colorectal carcinoma.
•Female cancers of the ovary, endometrium, and cervix.
CHEMOTHERAPY

21. Minimally sensitive
•Endocrine gland cancers.
•Malignant melanoma.
•Hepatocellular carcinoma.
•Renal carcinoma.
•Pancreatic carcinoma.
CHEMOTHERAPY

22. BI-PHOSPHONATES
•Tend to inhibit osteoclast re-absortion of bone matrix and decrease bone
turnover.
•There are three generations of bi-phosphonate currently available.

23. RADIOTHERAPY
Relevant contraindication : Neurologic
deficit
Absolute contraindication : Vertebral
collapse

24. ARTERIAL EMBOLISM IN SPINAL
METASTASIS

26. CERVICAL SPINE

27. INDICATIONS FOR OPERATIVE TREATMENT
1. Spinal instability
2. Pain resistible to conservative treatment (radiotherapy
chemotherapy)
3. Incomplete neurologic deficit resistible to any type of conservative
treatment
4. Rapid deterioration of the neurologic deficit

28. 5. Recurrence of tumor in an area that has been already submitted in
radiotherapy (at the maximum permitted levels)
6. Ambiguous histological diagnosis

29. FACTORS FOR EVALUATION
•The biology of the tumor
•The location
•The pain
•The neurologic deficit
•The spinal instability
•Life expectancy
•Overall condition of the patient

30. METHODS OF EVALUATION
•Tokuhashi scoring system
•Tomita surgical staging
•Karnofsky performance status scale
definitions rating (%) criteria

31. Tokuhashi’s criteria allow the definition of a pre
operative strategy and therefore considerable
variability in the choice of treatment ranging:
•Excisional operation should be performed on those who
scored above 9 points.
•A palliative operation should be performed on those who
scored under 5 points.

32. Simpler system of preoperative evaluation based on only
three
parameters:
•the degree of malignacy.
•the presence of visceral metastases.
•the presence of bony metastases.

33. TOMITA’S CLASSIFICATION SYSTEM

35. TYPES OF OPERATIVE TREATMENT
•Decompression
•Decompression– spondylodesia
•Debulking
•Piecemeal excision

37. ANTERIOR PROCEDURE
Up to three
vertebral
metastases

39. BREAST’S METASTASIS
•Vertebrectomy
•Vertebral substitution by cylinder
and
•Stabilization

42. POSTERIOR PROCEDURE
1. Vertebrae
2. Posterior vertebral elements
involvement
3. Poor general condition

44. Bilateral Mastectomy 35years ago

45. POSTERIOR DECOMPRESSION
±
OCCIPUT-CERVICAL
STABILIZATION

47. Combined procedures
(anterior – posterior

48. PNEUMON METASTASIS
N(+)

52. TOTAL VERTEBRECTOMY
ACCORDING TO TOMITA

53. TOTAL EN BLOC SPONDYLECTOMY (TES)
Harmful
Not useful
Useful