A case of recurrent malignant lesion to the spine from initially metastatic squamous lung carcinoma to T12.

1. Recurrent Metastatic Carcinoma
to the Lumbar Spine
• Medstar Union Memorial Spine Conference
• April 9th, 2019

2. 81-year-old woman with a chief complaint of low back
pain. Patient has noticed over the last 5 weeks she
has diffuse low back pain. Prior to that she was okay
with very few symptoms. She went to upper
Chesapeake Hospital where she was admitted for 2
days February 11 - February 13, 2019 almost two
weeks ago. She had CT and MRI performed at Harford
Memorial Hospital. She is self-referred here as I have
performed surgery on her spine in the past. She has
no radiculopathy. She was told she has recurrent
tumor in her spine. The radiation oncologist at upper
Chesapeake told her that she cannot have radiation to
her spine. She was given steroids at upper
Chesapeake and this has helped her symptoms. She
has chronic lower extremity numbness in her legs and
feet from her previous surgery in 2015. Patient is
status post spinal reconstruction surgery by myself
June 19, 2015 at upper Chesapeake. In 2015 the
patient had presented with a 2-1/2-week history of
ataxia, lower extremity weakness and numbness. A
biopsy of the T12 posterior elements revealed
metastatic tumor. There was compression of the
spinal cord at that time. Patient had resection of the
spinal tumor with partial T11, complete T12, partial L1
laminectomy decompression with a T11-L3 posterior
spinal arthrodesis using Depuy Expedium pedicle
screws and rods, use of allograft and bone graft. The
T12 pedicles were strong. The patient did extremely
well from the surgery and went home after 1-2 days.
This is the first time I have seen her back from surgery.
Postoperatively the patient had radiation treatment
and no chemotherapy. Following the radiation
treatment the patient had lower extremity
radiculopathy type symptoms which persists today.
She is now 3-1/2 years postop from this recurrent
metastatic tumor resection. The tumor type was CK
5/6+ p63 and negative CK 7 TDF–1. The patient has
had the opinion that the previous spinal surgery was a
complete success and she was asymptomatic up until
5 weeks ago.

3. 2019

4. HISTORY FROM
2015
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,

5. 2012

6. Office visit 6/10/15

8. CT 4/24/15
12
12

10. 5/5/15

12. 5/27/15
93% VERSUS 76% ACCURACY LYTIC VERSUS SCLEROTIC

13. PET 6/10/15

18. 6/11/15

23. ?

24. Thoracolumbar
junction is a
point of stress

25. 6/19/15 surgery
Do you need to fuse metastatic spinal reconstructions? Unnecessary Morbidity for low life
expentancy versus durable spine for possible remission time period postop;individualize rx

26. T11

27. T12

28. L1

29. Left L2; right screw fracture pedicle therefore

30. Right L3

31. Remarkable recovery, Home POD#1 Pod #4 ileus
weakness POD #14 PE L lower lobe pulmonary artery

32. Squamous cell lung ca treated with radiation EBRT 300
centigray times 10 (total 3,000 cGy) no chemo summer
2015; PE 2 weeks postop; 3.5 asymptomatic years fully
independent and functional

34. 2019
presentation

35. Feb 2019

36. T11 screws

37. T12 screws

38. L1
clockwise
L1

39. T11

40. L1

41. L1
L2
L3

43. L1

45. T12
L1
L2

48. L1

49. L1 body just inf
To screws

50. L1 body just inf
To screws

51. L2

52. L2 body almost L2L3 disc

53. L3 screw

56. Problem list:
1. 81 year old woman with pain
2. Recurrent tumor (squamous lung ca met
previous laminectomy T12) next level inferior
to L1 with R body destruction, severe L1L2
stenosis
3. Instability
4. Loose screws T11 and L3
5. Solid fusion
6. L1L2 anterior defect on right; is the fusion
adequate? Instrumentation sufficient?

60. 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.

61. 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

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

64. METASTASIS

66. ??????
??????
??????
??????
????

68. 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.

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

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

81. A case of a
compressive
metastatic
lesion of the
spine
compressing
the
neurological
elements into
a corner of
the spinal
canal

82. Why
is
the
cauda
equina
still
deviated
away
from the
tumor?

84. Spinal cord compression: surgery
versus radiation

85. study in the Lancet 2005 revealed spinal cord compression from metastatic disease

86. 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.

87. 100 patients randomized double blind

100. Lung Ca

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

106. 15% non-contiguous mets

108. 1,638,910/314,000,000=
1 in 192
Md: 31k/5,000k= 1 in 161

110. EXTERNAL BEAM RADIATION
XRT

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

118. Problem list:
1. 81 year old woman with pain
2. Recurrent tumor (squamous lung ca met
previous laminectomy T12) next level inferior
to L1 with R body destruction, severe L1L2
stenosis
3. Instability
4. Loose screws T11 and L3
5. Solid fusion
6. L1L2 anterior defect on right; is the fusion
adequate? Instrumentation sufficient?

119. Preop planning

121. Intraop a woodson elevator was inserted to See how
superior the resection was performed as there was
scar limiting exposure

122. L4postop

123. T10
postop

125. L1
L2
L1
2

127. •PATHOLOGY

128. THANKS

140. • Date of Operation
• March 8, 2019
• Preoperative Diagnosis (With AJCC Staging as Applicable)
• Recurrent metastatic tumor to the spine L1-L2
• Postoperative Diagnosis
• Same
• Operation (Laterality as Applicable)
• Revision thoracolumbar fusion T10-L4 with Depuy Expedium pedicle screw spinal instrumentation with removal of previous spinal instrumentation, revision resection of extradural metastatic carcinoma
from T12-L3 with partial corpectomy resection of L1-L2 vertebral body on the right, anterior reconstruction and fusion from T12-L2 with allograft
• Surgeon(s)
• Antoniades MD, Moatz MD
• Assistant
• none
• Anesthesia
• GETT
• IVF: 3.5 liters
• operative time 3.5 hours

141. • Chief Complaint
• back pain
• History of Present Illness
• 81-year-old woman with a chief complaint of low back pain. Patient has noticed over the last 5 weeks she has diffuse low back pain. Prior to that she was okay with very few symptoms. She went to upper
Chesapeake Hospital where she was admitted for 2 days February 11 - February 13, 2019 almost two weeks ago. She had CT and MRI performed at Harford Memorial Hospital. She is self-referred here as I
have performed surgery on her spine in the past. She has no radiculopathy. She was told she has recurrent tumor in her spine. Her current oncologist is Dr. Khawaja as Dr. Parsa retired from the practice..
The radiation oncologist at upper Chesapeake told her that she cannot have radiation to her spine. She was given steroids at upper Chesapeake and this has helped her symptoms. She has chronic lower
extremity numbness in her legs and feet from her previous surgery in 2015. The patient was offered spinal consultation at Upper Chesapeake but the patient chose to follow up with me as I have performed
surgery on her in the past. Upper Chesapeake has not contacted me about this patient.
• Past medical history right upper lobe lobectomy with resection of squamous cell carcinoma August 2012, hiatal hernia, small infrarenal aortic aneurysm, asthma, COPD, GERD, hyperlipidemia, TIA in the past,
paraesophageal hernia 2014, skin cancer nose, benign breast removal in the past, benign cyst removal in the past, bilateral total knee arthroplasty, colonoscopy, hysterectomy, bilateral tubal ligation, right
rotator cuff repair 2013, cystoscopy for hematuria 1993, emphysema, blood clots in the past.
• Patient is status post spinal reconstruction surgery by myself June 19, 2015 at upper Chesapeake. In 2015 the patient had presented with a 2-1/2-week history of ataxia, lower extremity weakness and
numbness. A biopsy of the T12 posterior elements revealed metastatic tumor. There was compression of the spinal cord at that time. Patient had resection of the spinal tumor with partial T11, complete
T12, partial L1 laminectomy decompression with a T11-L3 posterior spinal arthrodesis using Depuy Expedium pedicle screws and rods, use of allograft and bone graft. The T12 pedicles were strong. The
patient did extremely well from the surgery and went home after 1-2 days. She then presented to Harford Memorial Hospital with a postoperative pulmonary embolism in the postoperative period just
after surgery. At that point in time I requested that the patient be transferred to upper Chesapeake Hospital so that she can be evaluated. The patient refused transfer and her daughter Terry refused
transfer. The patient never followed up in my office as a result of the advice of her daughter Terry. This is the first time I have seen her back from surgery. Postoperatively the patient had radiation
treatment and no chemotherapy. Following the radiation treatment the patient had lower extremity radiculopathy type symptoms which persists today. She is now 3-1/2 years postop from this recurrent
metastatic tumor resection. The tumor type was CK 5/6+ p63 and negative CK 7 TDF–1. The patient has had the opinion that the previous spinal surgery was a complete success and she was asymptomatic
up until 5 weeks ago.
• Social history: The patient lives in Havre de Grace alone. She is very vibrant and does her own shopping, cooking, cleaning and taking care of herself and her home. She is accompanied by 2 of her daughters
Brenda and Linda. Brenda lives locally and Linda lives in Delaware. She also has another daughter Terry who is involved with the patient's medical decisions. She has 4 total children one deceased. She is a
non-smoker no alcohol currently. Patient quit cigarette smoking in 2004 prior to that 20-pack-year history.
• Current medications: Sucralfate 1 g a day, pantoprazole for hiatal hernia, simvastatin 20 mg, aspirin 81 mg, Atrovent inhaler, dexamethasone, Percocet as needed, lorazepam as needed for anxiety.
• MRI cervical and thoracic report UCMC from February 11, 2019 from Harford Memorial Hospital states cervical spine no tumor. Thoracic spine no tumor.

142. Pathology for Spine
Conference
July 10, 2015
By: Dr. Seiguer

143. 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.

144. 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.

145. S15-3211
Biopsy

147. CK5/6

148. p63

150. S15-3745
excision

152. *
*
*

153. * *
*
vessel

157. 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

159. UCMC spine
Conference
April 7, 2017

160. Case 1
gj
s17-1390
T-12
Tumor/paraspinal
mass

183. • 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

187. 1 in 200

188. 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
!?

189. 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

190. • 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

191. 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)

192. Hypertrophic pulmonary osteoarthropathy

193. Digital clubbing

194. Who should do the investigation
And how?